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REVISTA

ROMÂNĂ

de

PSIHIATRIE

Vol XVIII Nr. 4 December 2016

QUARTERLY

CNCSIS B+ p-ISSN: 1454-7848 e-ISSN: 2068-7176

COMITET DE REDACŢIERedactor şef: Dan PRELIPCEANURedactor-şefi adjuncți: Dragoş MARINESCU Aurel NIREŞTEANCOLECTIV REDACŢIONALDoina COZMANLiana DEHELEANMarieta GABOŞ GRECUMaria LADEACristinel ŞTEFĂNESCUCătălina TUDOSE

Secretar de redacţie: Valentin MATEI CONSILIU ŞTIINŢIFIC Vasile CHIRIŢĂ (membru de onoare al Academiei de Ştiinţe Medicale, Iaşi)Michael DAVIDSON (Professor, Sackler

School of Medicine Tel Aviv Univ., Mount Sinai School of Medicine, New York)

Virgil ENĂTESCU (membru al Academiei de Ştiinţe Medicale, Satu Mare)

Ioana MICLUŢIA (UMF Cluj-Napoca)Şerban IONESCU (Universitatea

Paris VIII, Universitatea Trois-Rivieres, Quebec)

Mircea LĂZĂRESCU (membru de onoare al Academiei de Ştiinţe Medicale, Timisoara)

Juan E. MEZZICH (Professor of Psychiatry and Director, Division of Psychiatric Epidemiology and International Center for Mental Health, Mount Sinai School of Medicine, New York University)

Sorin RIGA (cercetător principal gr.I)

Eliot SOREL (George Washington University, Washington DC)

Maria GRIGOROIU-ŞERBĂNESCU (cercetător principal gr.I)

Tudor UDRIŞTOIU (UMF Craiova)

Teodor T. POSTOLACHE, MD (Director, Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore)

Dan RUJESCU (Head of Psychiatric Genomics and Neurobiologyand of Division of Molecular and Clinical Neurobiology, Department of Psychiatry, Ludwig- Maximilians-University, Munchen)

ARPP

ASOCIAŢIA ROMÂNĂDE PSIHIATRIE ŞI PSIHOTERAPIE

www.romjpsychiat.ro

ROMANIAN JOURNAL OF PSYCHIATRY

CUPRINS

REZUMATE CONFERINȚA NAȚIONALĂ PSIHIATRIE ȘI SĂNĂTATE MINTALĂCRAIOVA, 05-08 OCTOMBRIE 2016

Cosmin O. Popa, Adrian Rus

Raluca Ileana Nica, Mihail Cristian Pîrlog

Tendințe în diagnosticarea psihiatrică la copii și adolescenți într-o unitate spitaliceasca între anii 1990 și 2014

Ilinca Mihailescu, Florina Rad, Cristina G. Anghel, Cornelia Paraipan,

Lucia E. Andrei, Liana Kobylinska, Iorgu D. Matei, Mircea B. Matei,

Iuliana Dobrescu

Contribuția terapiei cognitiv-comportamentale în tratamentul tulburării obsesiv-compulsive 145

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ARTICOLE DE SINTEZĂ

&

ARTICOLE ORIGINALE &

149

&

INDEX DE AUTORI 172

INSTRUCŢIUNI PENTRU AUTORI 173

Studiu comparativ între gradele de stigma personala și percepută, printre profesioniștii din sistemul de îngrijire psihiatrică

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Revista Română de Psihiatrie este indexată de Consiliul Naţional al Cercetării Ştiinţifice din Învăţământul Superior la categoria B+. Apare trimestrial.

Colegiul Medicilor din România acordă abonaţilor la această publicaţie 5 credite EMC/an.Articolele ştiinţifice publicate în revistă sunt creditate cu 80 credite EMC/articol.

Revista Română de Psihiatrie este editată de Asociaţia Română de Psihiatrie şi Psihoterapieşi Asociaţia Medicală Română

EDITORIAL

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REZUMATE CONFERINȚA NAȚIONALĂ PSIHIATRIE ȘI SĂNĂTATE MINTALĂCRAIOVA, 05-08 OCTOMBRIE 2016

PREZENTĂRI ORALE

SINDROMUL DE HIPOFRONTALIETATE ÎN PROGNOSTICUL SCHIZOFRENIEIDragos Marinescu, Ion Udristoiu, Felicia Militaru, Tudor Udristoiu, Ileana MarinescuUniversitatea de Medicină și Farmacie din Craiova

Schizofrenia, în modelul psihiatriei biologice, este considerată o afecțiune cu determinism cerebral în care sunt perturbate raporturi le de conectivi tate interneuronală, dar și de conectivitate anteroposterioară (fronto-occipitală) și interemisferică. Prognosticul afecțiunii este determinat într-o măsură importantă de precocitatea diagnosticului și a intervenției terapeutice, intervenție ce impune diferențierea în funcție de gradul de vulnerabilitate biologică. Vulnerabilitatea biologică este semnificativ crescută la pacienții cu schizofrenie proveniți din condițiile patologice ce perturbă neurodezvoltarea, prezentând un set de simptome ce sugerează această condiție: semne neurologice soft, convulsii febrile, perturbări ale sistemului autonom vegetativ cu alterarea ritmului cardiac, dar și deficite cognitive minore, dislexii, disgrafii și dificultăți de orientare stânga-dreapta.Vulnerabilitatea biologică primară semnalizată anterior poate fi agravată prin asocierea infecției streptococice betahemolitice, ce alterează conectivitatea cortico-striatală determinând fenomene de tip extrapiramidal prezente anterior oricărui tratament antipsihotic, dar și instalarea acestora în condițiile utilizării unor substanțe farmacologice blocante ale receptorilor de tip D2 (ex. metoclopramid). Această vulnerabilizare extrapiramidală este corelată cu disfuncția polului frontal, sindromul de hipofrontalietate fiind responsabil de persistența unei simptomatologii de tip negativ, depresiv, sindrom apato-abulic-anhedonic sau a unor elemente obsesional-compulsive cu rezistență terapeutică puternică.Identificarea riscurilor sindromului de hipofrontalietate la un pacient cu schizofrenie impune strategii terapeutice diferențiate cu evitarea utilizării antipsihoticelor cu capacitate de blocare puternică pentru receptorii de tip D2, și utilizarea unor modulatori dopaminergici care să permită menținerea unui raport funcțional între structurile frontale și striatale.Cuvinte cheie: schizofrenie, vulnerabilitate biologică, conec t iv i t a t e co r t i co - s t r i a t a l ă , s ind rom de hipofrontalietate.

THE HIPOFRONTALITY SYNDROME IN THE PROGNOSIS OF SCHIZOPHRENIAIn the model of biological psychiatry, schizophrenia is considered a disorder with cerebral origin where the interneuronal connections, as well as the antero-posterior

and interhemispheric links are altered. The prognosis of schizophrenia is influenced in a significant proportion by the early diagnosis and therapeutic intervention, the latter being differentiated based on the level of biological vulnerability. This vulnerability is high in patients with schizophrenia that have previous pathological conditions that interfere with neurodevelopment: soft neurological signs, fever convulsions, dysfunctions of the autonomic system that alter the cardiac rhythm, but also minor cognitive deficits, dyslexia, dysgraphia and left-right orientation difficulties.The primary biological vulnerability may be aggravated when infection with streptococcus betahemolyticus is present which alters the corticostriatal connectivity with secondary extrapyramidal-like symptoms before any antipsychotic treatment or their appearance when using D2-blocking substances (e.g., metoclopramid). This extrapyramidal vulnerabilization is correlated with the frontal lobe dysfunction that is responsible of the persistence of negative symptoms, apatho-abulic syndrome or obsessive-compulsive elements with high therapeutic resistance.Identifying the risks for the hipofrontality syndrome in a patient with schizophrenia imposes differentiated therapeutic strategies by avoiding powerful D2 blocking antipsychotics and employing dopaminergic modulators that could maintain a functional balance between the frontal and striatal structures.Keywords: schizophrenia, biological vulnerability, cortico-striatal connectivity, hypofrontality syndrome.

EFECTELE ADVERSE METABOLICE ALE MEDICAŢIEI PSIHOTROPE LA PACIENŢII CU PSIHOZĂ

1,2 2 2Liana Dehelean , Ana Romosan , Mihaela Manea , Ion 1,2 1,2 3Papava , Radu Romosan , Minodora Manea , Pompilia

1 1Dehelean , Mircea Dehelean1Universitatea de Medicină şi Farmacie Timișoara, Romania2Clinica Psihiatrică Timișoara, Romania3Universitatea de Medicină şi Farmacie Cluj-Napoca, Romania

Introducere. Datele din literatură sugerează că la pacienții cu schizofrenie, factori ca stilul de viață, medicația și abuzul de droguri pot creste riscul apariției disfuncțiilor metabolice. Obiective. Identificarea prezenţei sindromului metabolic (SM) la pacienți tratați în ambulatoriu cu antipsihotice injectabile de tip long acting (LAI). Metode: Studiu prospectiv realizat pe două loturi, unul format din pacienţi aflaţi pe tratament cu olanzapină, iar

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Rezumate Conferința națională psihiatrie și sănătate mintală Craiova, 05-08 octombrie 2016

celălalt pe pacienți tratați cu risperidonă. Toţi subiecţii au fost pe tratament LAI de cel puţin 3 luni. Am analizat următorii parametrii: vârsta, sexul, medicaţia şi prezenţa SM. Diagnosticul de SM a fost stabilit conform criteriilor Federaţiei Internaţionale de Diabet 2006 (hipertensiune, hiperglicemie, nivel redus al HDL colesterol, hipertrigliceridemie, obezitate abdominală). Glicemia a jeun a fost măsurată utilizând glucometrul PalmLab SC-101, iar profilul lipidic folosind lipidometrul LipidPro ILM-0001A. Rezultate. Lotul a fost format din 37 (57.8%) bărbaţi şi 27 (42.2%) femei cu o vârstă medie de 41.25 ani. 33 (51.6%) de pacienţi se află pe tratament cu olanzapină şi 31 (48.4%) pe tratament cu risperidonă. Criteriile pentru SM au fost întrunite la 38 (59.4%) de pacienţi dintre care 17 (44.7%) pe olanzapină şi 21 (55.3%) pe risperidonă. 22 (52.4%) de pacienţi pe olanzapină şi 20 (47.6%) pe risperidonă au avut asociat un timostabilizator. 24 (57.1%) dintre pacienţii cu timostabilizator asociat, au prezentat SM. Pacienţii cu SM au avut o durată mai lungă de evoluţie a psihozei şi o durată mai lungă a tratamentului antipsihotic LAI. Nu am găsit diferenţe semnificative între pacienţii cu SM aflaţi pe olanzapină şi cei aflaţi pe risperidonă în ceea ce priveşte durata totală a psihozei, respectiv durata tratamentului antipsihotic LAI. Concluzii. Rezultatele studiului sugerează că indiferent de antipsihoticul ales, olanzapină sau risperidonă, nu au existat diferenţe semnificative între loturi din punctul de vedere al prevalenţei SM. Cuvinte cheie: sindrom metabolic, schizofrenie, tratament LAI.

M E T A B O L I C S I D E E F F E C T S O F PSYCHOTROPIC MEDICATION IN PATIENTS WITH PSYCHOSISIntroduction. Literature data suggests that in patients with schizophrenia factors such as life style, medication and substance abuse may increase the risk of metabolic changes.Objectives. The aim of the study is to identify the presence of the metabolic syndrome (MS) in outpatients receiving long acting injectable (LAI) antipsychotic treatment.Methods. This prospective study was conducted on two samples of outpatients with psychosis treated with LAI second generation antipsychotics: olanzapine and risperidone. All subjects received LAI treatment for at least 3 months. We analyzed the following parameters: age, gender, medication and the presence of the metabolic syndrome. The diagnosis of MS was established according to the 2006 International Federation of Diabetes diagnostic criteria (hypertension, hyperglycemia, low HDL cholesterol, hypertriglyceridemia, abdominal obesity). Fasting glycaemia was measured using the PalmLab SC-101 glucometer. The lipid profile was determined using the LipidPro ILM-0001A lipidometer. Results. The sample consisted of 37 (57.8%) men and 27 (42.2%) women with a mean age of 41.25 years. 33 (51.6%) patients received olanzapine LAI and 31 (48.4%) patients received risperidone LAI. 38 (59.4%) patients fulfilled the criteria for MS, 17 (44.7%) on olanzapine and 21 (55.3%) on risperidone. A mood stabilizer was associated in 22 patients (52.4%) on olanzapine and 20 (47.6%) on risperidone. 24 (57.1%) of the patients receiving a mood stabilizer fulfilled the criteria for MS.

The patients with MS had a longer duration of the psychosis and spent more time on LAI treatment. We found no differences between patients with MS on olanzapine LAI and risperidone LAI regarding the duration of the psychosis and the duration of LAI treatment, respectively. Conclusion. Our findings suggest that regardless the chosen antipsychotic, olanzapine or risperidone, there were no significant differences in the prevalence of the MS.Keywords: metabolic syndrome, schizophrenia, LAI treatment.

DIMENSIUNEA DEZINTEGRATIVĂ A GÂNDIRII ȘI PERSONALITĂȚII ÎN SCHIZOFRENIA HEBEFRENICĂ

1 2 3Simona Trifu , Eduard George Carp , Raluca Ioana Petru1Universitatea de Medicină și Farmacie „Carol Davila” București, Romania2Spitalul de Psihiatrie Săpunari, Romania3Cabinet Individual de Psihologie, București, Romania

Motivația alegerii temei de cercetare. Schizofrenia hebefrenică reprezintă o piatră de încercare în ceea ce privește managementul pe termen lung al cazului, mai ales când este vorba de acceptarea de către familie a evoluției trenante și a dimensiunii deteriorative a cogniției și intelectului. La limită, debutul precoce al unei astfel de forme de Schizofrenie frizează Tulburările de spectru dezintegrativ din arealul nosografiei pedopsihiatriei.Obiective. Ne propunem prezentare unui caz de Schizofrenie hebefrenică, având debutul la 13 ani, survenită pe un fond cu înalt nivel de funcționare intelectuală și socială.Ipoteză. Pacienta coresunde tipului III de Schizofrenie din calsificarea lui Crown, în care caracteristicile importante sunt: vorbirea și comportamentul dezorganizat, defectele cognitive şi de atenţie, prezența unui amalgam de simptome, atât pozitive, cât și negative.Metode. RMN cerebral, EEG computerizat, examen neurologic, interviu psihiatric, monitorizare a evoluției zilnice sub tratament, harta vieții, heteroanamneză, teste psihologice, participare la activitați de ergoterapie și psihoeducație pe perioada unei internări prelungite.Rezultate. Investigarea fondului de organicitate cerebrală evidențiază anormalități de tipul unui chist leptomeningeal cu diametrul de 1 cm parasagital stâng și un lipom la nivelul corpului callos. Pacienta a prezentat o evoluție de tip deteriorativ la nivelul cogniției și comportamentului, mergând până la pierderea controlului sfincterian, halucinații auditive continue imperative, voci ce îi dictează comportamente suicidare cu motivație bizară. Calitate slabă a remisiunilor și rezistenţă la tratament (leucopenie sub Clozapină, accentuarea agitației sub Paliperidonă).Concluzii. Antipsihoticele au influențat puțin dimensiunea productivă a bolii, cu persistența fenomenologiei de tip tulburări formale de gândire, limbaj și comunicare (ilogisme, aproximări de cuvinte, perseverare), alături de sugestibilitate marcată și regresie.Cuvinte cheie: Schizofrenie hebefrenică, Tulburări din spectrul dezintegrativ, rezistență la tratament, organicitate cerebrală, inadecvare afectivă și comportamentală, deteriorarea cogniției.

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THE DISINTEGRATIVE DIMENSION OF T H I N K I N G A N D P E R S O N A L I T Y I N HEBEPHRENIC SCHIZOPHRENIAReasons for choosing the research topic. Hebephrenic Schizophrenia is a touchstone in terms of long-term management of the case, especially when it comes to acceptance by the patient's family of the lingering evolution and the disintegrative dimension of cognition and intellect. At the limit, the early onset of such form of schizophrenia is almost at the verge of disintegrative spectrum disorders from Pediatric Psychiatry.Objectives. We would like to present a case of Hebephrenic Schizophrenia, with onset at the age of 13, on a background of high level intellectual and social functioning.Hypothesis. The patient corresponds to type III Schizophrenia according to Crown's classification, the important characteristics are: disorganized speech and behavior, attention and cognitive deficits, the presence of an amalgam of symptoms, both positive and negative.Methods for Monitoring and Evaluation. Computerized EEG, brain MRI, psychiatric interview, daily monitoring of the developments during treatment, life mapping, heteroanamnesis, psychological tests, participation in occupational therapy and psycho-education during a prolonged hospitalization.Results. Investigation reveals organic structure abnormalities such as a leptomeningeal parasagittal left cyst with a diameter of 1 cm and a lipoma at the corpus callosum level. The patient showed a progression of deteriorative type of cognition and behavior, up to and loss of sphincter control, ceaseless imperative auditory hallucinations, voices dictating suicidal acts of bizarre motivations. Poor remission and treatment failure (leukopenia under clozapine, increased agitation under paliperidone).Conclusions. Antipsychotics influenced less productive dimension of the disease, with persistence phenomenology of formal thought, language and communication disorders (deficits in logical reasoning, approximations of words, persevering), along with regression and high levels of suggestibility. Keywords: Hebephrenic Schizophrenia, disintegrative spectrum disorders, treatment resistant, cerebral organicity, affective and behavioral inadequacy, deterioration of cognition.

TULBURĂRI MENTALE ORGANICE (INCLUSIV TULBURĂRI SIMPTOMATICE) ÎN CAUZELE CIVILE

1 1 2Anca Iftodi , Corina Tudor , Gabriela Costea , Daniel 3Vasile

1Spitalul Universitar de Urgenta Militar Central „Dr. Carol Davila” București2Institutul Național de Medicină Legală „Mina Minovici” București, Romania3Universitatea de Medicină și Farmacie „Carol Davila” București, Romania

Introducere. Diagnosticul clinic al unei tulburări mentale nu este suficient pentru a stabili, în scop legal capacitatea psihică/discernământul/competența psihică specifică, acestea fiind prezumate. Reversul trebuie demonstrat prin verificare cognitivă și volitivă. Cele mai mari dificultăți se

întâlnesc în cauzele civile la persoane cu antecedente psihiatrice încadrate în grupa tulburărilor mentale organice. Conceptele expertizelor medico-legale psihiatrice se înscriu în sfera analizei fenomenologice a medicinei centrate pe persoană și a medicinei bazate pe dovezi.Scop. Se urmărește importanța dovezilor non-medicale în stabilirea răspunsului la obiectivele instanțelor și în argumentarea acestuia.Metodă. Studiul este retrospectiv (perioada 2005-2013). S-au analizat 364 de rapoarte de nouă expertiză medico-legală psihiatrică, solicitate în cauze civile. S-au urmărit un număr de 30 de grupe de variabile, care urmăresc informațiile medicale și non-medicale ale pacienților. A fost acordată o importanță deosebită comorbidităților și contextului implicării în faptul juridic.Concluzii. Există diferențe de abordare a verificării cognitive și volitive în spețele civile privind interdicția față de cauzele ce vizează translația de proprietate. În cauzele civile privind competența psihică specifică de a întocmi acte de translație, absența informațiilor non-medicale necesare sau nepunerea la dispoziție a documentelor medicale solicitate, au condus la concluzii neadecvate soluționării juridice (”este posibil” sau ”nu se poate stabili”).Cuvinte cheie: competență psihică specifică, tulburări mentale organice, expertize medico-legale psihiatrice.

ORGANIC, INCLUDING SYMPTOMATIC, MENTAL DISORDERS IN CIVIL Introduction. The clinical diagnosis of a mental disorder is not sufficient to legally establish the mental capacity / discernment / specific psychiatric competency, all these being presumed. The reverse must be demonstrated by cognitive and volitional evaluation. The most difficult civil cases are about patients with a psychiatric history, related to the group of organic mental disorders. The concepts of forensic psychiatric expertise fall within phenomenological analysis of person-centered medicine and of evidence-based medicine.Purpose. The emphasis falls on non-medical evidence in establishing the response to court objectives and its argumentation.Method. The study is retrospective (2005-2013), contains 364 reports of new psychiatric forensic expertise, that were required in civil cases, and monitors 30 groups of variables, aimed at medical and non-medical information of patients. Both comorbidities and the context of involvement in the legal fact have been shown a great importance.Conclusions. There are different approaches to cognitive and volitional evaluation in civil court cases regarding the causes of ownership transfer ban. In civil cases related to specific psychiatric competency of creating ownership transfer documents, the absence of necessary non-medical information, or the unavailability of required medical documents, led to inadequate conclusions for legal resolution (”it might be possible” or ”cannot be determined”).Keywords: specific psychiatric competency; organic mental disorders; psychiatric forensic expertise.

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A B O R D A R E A T U L B U R Ă R I L O R D E C O M P O RTA M E N T D I N T U L B U R Ă R I L E NEURODEGERATIVE – DIN PERSPECTIVA RECENTELOR NORME DE APLICARE A LEGII DE SĂNĂTATE MINTALĂ

1 2 1Cătălina Tudose , Maria Moglan , Ana Giurgiuca , Maria 3 3 1Lupu , Dana Iordan , Raluca Tipa

1Universitatea de Medicină si Farmacie "Carol Davila", București, România2Societatea Română de Sprijin a Vârstnicilor și a Suferinzilor cu Afecțiuni de tip Alzheimer, București, România3Spitalul Clinic De Psihiatrie "Prof. Dr. Al. Obregia", București, România

Majoritatea pacienților care prezintă simptome psihotice si comportamentale in cursul evoluției tulburărilor neuro-cognitive constituie o cazuistică de urgență. De cele mai multe ori, pacienții nu au fost examinați de nici un specialist până la data debutului acestor simptome. În consecință, aparținătorii solicită direct camerele de gardă ale spitalelor de psihiatrie pentru internare în regim non-voluntar. Această realitate este explicată în principal prin nediagnosticarea sau diagnosticarea tardivă a demențelor și prin lipsa serviciilor specializate pentru prevenția, îngrijirea și recuperarea pacienților suferinzi de demență, cu manifestări psihoticeConform recentelor Norme de Aplicare a a Legii sănătăţii mintale şi a protecţiei persoanelor cu tulburări psihice nr. 487/2002 publicat in M.O. 340/05.05.2016, aceste cazuri se încadrează în categoria celor care necesită declanşarea procedurii de internare nevoluntară respectiv prin:a) prezenţa comportamentului violent acut pe fondul unei tulburări psihice;b) prezenţa riscului evident şi iminent de vătămare pentru sine sau pentru alte persoane din cauza unei tulburări psihice;c) motive medicale întemeiate care indică faptul că absenţa instituirii imediate a unui tratament adecvat ar creşte riscul pentru un comportament care aduce vătămare pentru sine sau pentru alte persoane sau deteriorare gravă a sănătăţii mintale.Supravegherea, monitorizarea si protecția acestor persoane extrem de vulnerabile devine o adevărată “piatră de încercare” pentru psihiatri, medicul devenind singurul responsabil și pasibil de pedeapsă, conform legislației în vigoare, pentru îngrijiri neadecvate și expunerea pacientului la riscuri necontrolabile. Acest lucru se datorează lipsei condițiilor adecvate de supraveghere diferențiată și prin mijloace specifice – de izolare, contentie etc. adaptate persoanelor vârstnice, a psihopatologiilor multiple din secțiile de internare nonvoluntară. De asemenea inexistenta serviciilor de psihogeriatrie de legătură, care să asigure tratamentulcomorbidităților multiple, limiteaza accesul rapid al pacientului la asistența concomitentă de urgență de specialitate și uneori chiar la interventiile de terapie intensivă.În lucrarea prezentă sunt luate în discuție posibile soluții pentru îmbunătățirea condițiilor de tratament și îngrijire ale pacienților cu tulburări de comportament din tulburările neurodegerative și în consecința a condițiilor de munca ale echipei terapeutice psihiatrice.

Cuvinte cheie : tulburari neurodegenerative, comportament, aspecte legale.

M E N TA L H E A LT H - C A R E S E R V I C E S APPROACHES OF BEHAVIORAL SYMPTOMS IN NEURODEGENERATIVE DISORDERS – A VIEW I N R E S P E C T T O T H E R E C E N T IMPLEMENTATION OF THE NORMS FOR MENTAL HEALTH LAWMost patients who develop behavioral and psychotic symptoms in neuro-cognitive disorders require emergency psychiatric care and interventions. Most of the time these patients are not examined by a psychiatrist before the onset of the above-mentioned symptoms. As consequence, caregivers turn directly to the emergency psychiatric department and request compulsory admission.This is explained mainly by the lack of diagnosis (or a delayed diagnosis) of dementia and the lack of specialized services for prevention, care and rehabilitation of patients suffering from dementia and experiencing behavioral and psychotic symptoms. According to the recent implementation of Norms for the Mental Health Law no 487/2002 published in M.O. 340/05.05.2016, these patients fall into the category of those who require the compulsory admissions, as follows:a) presence of acute, violent behavior as a consequence of a psychiatric disorderb) the presence of an obvious and imminent risk of self-harming or harming others, caused by a mental disorderc) medical based reasons which indicate that the lack of immediate establishment of appropriate treatment could increase the risk of self-harming and harming others or the serious deterioration of mental health. Supervision, follow-up and protection of these highly vulnerable patient categories become a true stepping stone for psychiatrists and, according to the acting mental health law, doctors are the only ones responsible and are held accountable for the inadequate patient care. This is the result of an inadequate environment for providing focused patient surveillance and by proper means of isolation, physical restraint for the elderly and presence of mixed psychopathology in the compulsory admission wards.Moreover, the complete lack of liaison old age psychiatry services, which should ensure the treatment of multiple comorbidities, limits the patients' access to the specialized emergency care and even to the intensive care units. In this paper we discuss possible solutions for improving the treatment and care of patients with behavioral and psychotic symptoms in neuro-degenerative disorders and improving the working conditions for the psychiatric therapy team.Keywords: neurodegenerative disorders, behavior, legal issues.

C L I N I C A L P H A R M A C O L O G Y O F ANTIPSYCHOTICSMichel BourinUniversity of Nantes France

This presentation will concentrate on the clinical pharmacology, in particular pharmacodynamic data, related to atypical antipsychotics, clozapine, risperidone,

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paliperidone, olanzapine, quetiapine, amisulpride, ziprasidone, aripiprazole, asenapine, iloperidone, and lurasidone. A summary of their acute pharmacokinetics properties are also reported. Four new second-generation antipsychotics are available: iloperidone, asenapine, lurasidone. Similar to ziprasidone and aripiprazole, these new agents are advisable for the lower propensity to give weight gain and metabolic abnormalities in comparison with older second-generation antipsychotics such as olanzapine or clozapine. Actually lurasidone seems to be best in terms of minimizing unwanted alterations in body weight and metabolic variables. Therapeutic drug monitoring is not strictly necessary for all of the new antipsychotic drugs because there are no unequivocal data supporting a relationship between plasma drug levels and clinical outcomes or side effects. The exception can be represented by clozapine for which plasma levels of 350-420 ng/ml are reported to be associated with an increased probability of a good clinical response. Also for olanzapine an established therapeutic range (20-50 ng/ml) is proposed to yield an optimal response and minimize side effects. For the last 30 years, drugs targeting serotonin receptors (5-HTR) have been intensively investigated in schizophrenia. New drugs targeting 5-HTRs are under development in patients with schizophrenia. Antipsychotics reduce positive symptoms of schizophrenia (delusions, hallucinations and disordered thought), but have undesirable side effects. Moreover, satisfactory treatment of negative symptoms (apathy, poverty of speech, lack of interest in social interactions) and cognitive dysfunction is currently not available.Keywords : ant ipsychot ics , new t reatments , pharmacology.

A S P E C T E F U N D A M E N T A L E A L E FENOTIPIZĂRII PSIHICEGavril Cornuțiu, Oana Leț-CornuțiuSpitalul Clinic Municipal „Dr. Gavril Curteanu” Oradea, Romania

Pornind de la problema Piaget-Chomski: „cât este înnăscut și cât este câștigat?” și ca alegație, ținând cont de concluzia celui mai mare biolog al începutului de secol XX, Mayr, „fenotipul este rezultatul interacțiunii genotipului cu mediul”, autorii analizează și sintetizează noțional răspunsul cel mai pertinent din punct de vedere științific. Pentru aceasta introduc noțiunea de configurație ontogenică, prin care se înțelege nu doar structura și dinamica istorică a mediului, dar și bagajul și istoricul experienței individului. Aceasta permite o perspectivă psihoontogenetică a fenotipizării psihismului, introducând în formulă și factorul cultural prin intermediul arhetipurilor.În concluzie, autorii afirmă că ființa umană este o sinteză a bagajului genetic și a configurației ontogenetice în proporții variabile în jurul semnului de egalitate.Cuvinte cheie: fenotipizare, bagaj genetic, configurație ontogenetică.

FUNDAMENTAL ASPECTS OF PSYCHIC PHENOTYPINGStarting from the question of Piaget-Chomski „how much is innate and how much is gained” and considering the conclusion of Mayr, the greatest biologist of the beginning

of the 20th century, „the phenotype is the result of the interaction between the genotype and the environment”, the authors analyze and synthesize the most pertinent answer from the scientific perspective. For this, we introduce the notion of ontogenetic configuration, meaning not only the historical structure and dynamics of the environment, but also the history of individual's experiences. Thus, we may have a psycho-ontogenetic perspective on psychic phenotyping by employing the cultural factor through the archetypes. In conclusion, we state that the human being is a synthesis of the genetic pool and the ontogenetic configuration in variable, but almost equal proportions.Keywords: phenotyping, genetic pool, ontogenetic configuration.

DEPERSONALIZAREA PSIHOTICĂMircea Lăzărescu, Jeni Blajovan, Cristina Bredicean, Claudia HomoroganClinica de Psihiatrie „Eduard Pamfil” Timişoara, Romania

Sindromul depersonalizării, constând în sentimentul pierderii identităţii psihocorporale şi a adeziunii subiective la lume, a fost descris în sec.XIX şi identificat ulterior în majoritatea tulburărilor psihotice dar şi nevrotice (t.obsesiv-compulsivă, t.anxios-fobică, t.hysteric disociativă, t.depresivă etc.). În DSM-IV-5, el a fost cantonat la clasa tulburărilor disociative. Cercetările fenomenologice din ultimele două decenii, readuc în discuţie depersonalizarea din schizofrenia negativă (Parnas, Saas, Raballo). Se reactualizează de asemenea viziunea lui Jaspers care corela strând delirul primar cu sindromul depersonalizare derealizare (sentimentele existenţiale a lui Radcliff). Cercetarea de faţă se concentrează pe patologia delirant paranoidă care este interpretată ca un proces de „trans-personalizare” psihopatologică. Sunt prelucrate 50 cazuri din Registrul de cazuri pentru psihoze Timişoara. Sindromul depersonalizare derealizare este interpretat ca având la bază o disfuncţie psiho-cerebrală la nivelul de articulare între psihismul specific antropologic şi psihismul biologic care este prezent în fiecare om.Cuvinte cheie: depersonalizare, psihoză, fenomenologie.

PSYCHOTIC DEPERSONALIZATIONThe syndrome of depersonalization, consisting of a sense of loss of the psiho-corporal identity and a subjective adherence to world, was described in the 19th century and afterwards identified in most of psychotic disorder, but also in the neurotic ones (obsessive-compulsive disorder, phobic anxiety disorder, hysteric dissociative disorder, depressive disorder and so on). In DSM-IV-5, it was included in the dissociative disorders class. The phenomenological researches from the last two decades bring forward the depersonalization of negative schizophrenia (Parnas, Saas, Raballo). There is also an update on Jasper's point of view that closely correlated the primary delusion with Depersonalization-derealization syndrome (Radcliff's existential feelings). This research focuses on the paranoid delusional pathology which is interpreted as a psychopathological process of “trans-personalization”. 50 cases from the Register for psychosis in Timisoara are included in this study. The

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Depersonalization-derealization syndrome is interpreted as having at the base a psycho-cerebral dysfunction between the specific anthropological psychism and the biological psychism which exists in each person.K e y w o r d s : d e p e r s o n a l i z a t i o n , p s y c h o s i s , phenomenology.

DEBATES AND DILEMMAS IN PSYCHIATRYMichael DavidsonSackler School of Medicine, Tel Aviv University, Israel

Introduction. Schizophrenia is characterized by positive and negative psychotic symptoms and often by cognitive impairment. Currently available antipsychotic drugs, all of which to varying degrees have anti-dopaminergic activity, ameliorate positive symptoms in about two thirds of acutely ill patients. Drugs such as amisulpride and clozapine produce, on or only negligible benefits on negative symptoms and, no benefits on cognitive impairment both of which are the main contributors to the social and vocational difficulties in this disease. Even when antipsychotics improve negative symptoms, this is probably secondary to the improvement in positive symptoms and/or EPS and not a direct, specific effect on negative symptom. According to the Patient Outcomes Research Team schizophrenia guidelines (PORT), no pharmacologic treatment for negative symptoms has proven to have sufficient evidence to support a treatment recommendation. Basic research indicates that pharmacologically manipulated N methyl-D-aspartic acid (NMDA)/glutamate neurotransmission, via glycine reuptake, might benefit negative symptoms. Several clinical trials supported this notion, but this was not replicated in a subsequent large multi-center trial. Hence, the search for drugs with broader efficacy beyond positive symptoms such as negative symptoms and cognitive functioning as well an improved tolerability profile, remains a priority.Method. MIN-101 is a novel cyclic amido derivative, which has high equipotent affinities for sigma2 and 5 hydroxytryptamine2A (5-HT2A) receptors (inhibitory constants (Ki) 7.53 and 8.19 nmol/L for 5-HT2A and sigma2 respectively. Although MIN-101 has no affinities for pre or post-synaptic dopaminergic (DA) receptors it is very probable that sigma2 receptors are implicated in the modulation of DA and glutamatergic pathways. This multi-national Phase 2b trial enrolled 244 patients diagnosed with schizophrenia who were symptomatically

stable for ≥ 3 months prior to entering the trial and had

scores ≥ 20 on the negative scale of the Positive and Negative Syndrome Scale (PANSS). Patients were randomized to monotherapy with MIN 101 32 mg/day, MIN-101 64 mg/day, or placebo in a 1:1:1 ratio.Results: Statistically significant reduction in the primary endpoint score was demonstrated for MIN-101 32 mg and

64 mg compared to placebo (p ≤ 0.022, ES=0.45 and ≤ 0.003, ES=0.58, respectively). Similar effects on most of the secondary measurements such the PANSS negative symptoms and general psychopathology scales, PANSS total score, CGI, BACS, CDSS, and PSP supported these findings. There were no statistically significant differences in PANSS positive subscale scores between MIN 101 and placebo.

Conclusions: MIN-101 at dosages of 32 and 64 mg/day demonstrated statistically significant efficacy of medium effect size in reducing negative symptoms and good tolerability in stable schizophrenia patients.Keywords: schizophrenia, negative symptoms, treatment.

EVOLUȚIA REACȚIILOR ACUTE LA STRES S E V E R S P R E P S I H O Z Ă D E L I R A N T Ă ENDOGENĂIon Coşciug, Victor Lăcustă, Inga Deliv, Irina PădureUniversitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”,Chișinău, Republica Moldova

Experiența practică a demonstrat că, în unele cazuri reacțiile acute la stres sever pot evolua spre o psihoză delirantă endogenă.Scopul lucrării a vizat studierea evoluției în timp a diferitor sindroame psihopatologice din cadrul reacțiilor acute la stres sever în funcție de unele particularități ale personalității.Material și metodă Au fost investigați retrospectiv clinic (criteriile CIM 10), clinico-psihologic (testul MMPI; Scalele Ch. Spielberger pentru anxietatea trăsătură de caracter și anxietatea situațională) și paraclinic (CT, RMN, EEG ș.a. pentru a exclude afectarea organică cerebrală) - 63 pacienți cu reacții acute la stres sever, care s-au manifestat clinic prin diverse sindroame psihopatologice. Rezultate Sindroamele psihopatologice depistate la pacienții investigați au fost: sindromul paranoid (75% cazuri); halucinator-paranoid (14,1%); depresiv-paranoid (7,8%) și obsesiv-compulsiv (3,1% cazuri). În 26,6% cazuri (18 pacienți) s-au depistat indici crescuți pe scalele “6” – Paranoia și “7” – Anxietatea ale testului MMPI, asociați cu nivel înalt de anxietate trăsătură, dar și anxietate situațională în conformitate cu scalele Ch. Spielberger. La 15 pacienți (23,8%) din cei 63, reacția acută la stres sever a evoluat spre psihoză delirantă endogenă. Diverse sindroame psihopatologice au evoluat în timp spre psihoză în proporție diferită. Astfel, spre psihoză delirantă endogenă au evoluat 7 pacienți (46,67%) dintre cei la care reacția acută la stres sever s-a manifestat prin sindrom paranoid; 5 (33,33%) cu sindrom halucinator-paranoid; 2 (13,34%) cu sindrom obsesiv-compulsiv și 1 (6,67%) la care a fost prezent sindromul depresiv-paranoid.Concluzii 1) Reacțiile acute la stres sever sunt asociate cu un risc mai mare de evoluție spre psihoză delirantă endogenă la pacienții cu indici crescuți pe scalele “Paranoia” și „Anxietatea” în profilul personalității, în special când nivelul anxietății trăsătură de caracter este înalt. 2) Diverse sindroame psihopatologice din cadrul reacțiilor acute la stres sever pot evolua spre psihoză delirantă endogenă în proporție diferită.Cuvinte cheie: reacție acută la stres sever; tulburare delirantă endogenă; profilul personalității.

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THE EVOLUTION OF ACUTE STRESS REACTIONS TO DELUSIONAL ENDOGENOUS PSYCHOSISPractical experience has shown that in some cases acute stress reactions may evolve to severe delusional endogenous psychosis.The aim of the work was to study the evolution of various psychopathological syndromes in the acute stress reactions depending on some peculiarities of personality.Materials and methods. Sixty-three patients with acute stress reactions, which were manifested clinically through various psychopathological syndromes, were investigated retrospectively clinically (criteria ICD 10), clinico-psychologically (MMPI test, scales Ch. Spielberger trait for anxiety and situational anxiety) and laboratory (CT, MRI, EEG, etc. to rule out organic brain damage).Results. Psychopathological syndromes found in the investigated patients were: paranoia (75% of cases); hallucinatory-paranoid (14.1%); depressive-paranoid (7.8%) and obsessive-compulsive (3.1% of cases). In 26.6% of cases (18 patients) were found high indices on scales "6" - Paranoia and "7" – Anxiety, from MMPI test, that where associated with high levels of trait anxiety, and situational anxiety, from Ch. Spielberger scales. In 23,8% (15 patients from the same 63) acute stress reactions evolved into severe delusional endogenous psychosis. Over time various psychopathological syndromes have evolved to psychosis in different proportion. Thus, towards delusional endogenous psychosis have evolved 7 patients (46.67%) from the acute stress reactions which was severely manifested by paranoia syndrome; 5 (33.33%) with hallucinatory-paranoid syndrome, two (13.34%) with obsessive-compulsive and one (6.67%) with depressive-paranoid syndrome.Conclusions 1) Acute stress reactions are associated with a higher risk of progression to delusional endogenous psychosis in patients with high indices on paranoia and anxiety scales on MMPI personality profile, especially when there are high levels of trait anxiety, on Ch. Spielberger scales. 2) Various psychopathological syndromes in the acute stress reactions can evolve towards delusional endogenous psychosis in different proportion.Keywords: acute stress reactions, endogenous delusional psychosis, personality profile.

S T U D I U P R I V I N D F R E C V E N Ț A PERSONALITĂȚII D ȘI IMPACTULUI ACESTEIA ASUPRA CALITĂȚII VIEȚII LA PACIENȚII CU DIABET ZAHARAT TIP II DISPENSARIZAȚI AMBULATOR LA NIVELUL JUDEȚULUI TIMIȘ

1 1 1Virgil-Radu Enătescu , Ion Papavă , Radu Romoșan , 1 2 1Alexandra Grozavu , Virgil Enătescu , Ileana Enătescu

1Universitatea de Medicină și Farmacie “Victor Babeș” Timișoara, Romania2Ambulatorul de Psihiatrie a „Clinicii West Medica” Satu Mare, Romania

Obiectiv. Cercetare a avut ca scop identificarea frecvenței personalității de tip D la pacienții cu diabet zaharat tip II tratați în ambulatoriul de specialitate la nivelul județului Timiș. De asemenea, au fost analizați și cuantificați factorii psihopatologici care se asociază în mod semnificativ la acești pacienți. Material și metodă. A fost efectuată o cercetare

transversală la nivelul Clinici de Diabet și Boli Metabolice din Timișoara care a inclus inițial la prima evaluare 79 de pacienți internați cu un diagnostic de diabet zaharat tip II (DZ tip II). Criteriile de excludere au fost reprezentate de existența unei tulburări psihice cunoscute și în curs de tratament. Prezența personalității D a fost stabilită prin utilizarea scalei DS-14. Anxietatea stare și trăsătură a fost evaluată cu ajutorul scalei STAI-Y. Calitatea vieții a fost evaluată cu ajutorul scalei Calitatea Plăcerii Vieții și Chestionarul Satisfacției (Q-LES-Q-SF). Prezența depresiei a fost cuantificată cu ajutorul scalei Beck Depression Inventory versiunea I. Datele au fost analizate statistic cu programul SPSS versiunea 17 pentru Windows.Rezultate. Personalitatea D a fost extrem de frecventă la nivelul lotului studiat 38 de pacienți satisfăcând criteriile pentru prezența acesteia (48,1%). Cei cu personalitate D prezentă și DZ tip II au prezentat medii ale scorurilor semnificativ mai mici la următoarele domenii ale calității și plăcerii vieții referitoare la relațiile sociale, funcționarea cotidiană, activitate sexuală, forma fizică și în domeniu muncă și hobbyuri (p < 0,05). Atât anxietatea stare (t = 3,410; p = 0,001) cât și trăsătură (t = 3,316; p = 0,001) au prezentat medii ale scorurilor semnificativ mai mari la cei cu personalitate D prezentă comparativ cu cei cu DZ tip II fără personalitate D. pacienții diabetici cu personalitate D prezentă au prezentat nivele de depresie semnificativ mai mari comparativ cu cei fără personalitate D (t = 4,308; p < 0,001).Concluzii. Prezența personalității D interferează în mod semnificativ și negativ cu mai multe domenii ale calității vieții pacienților cu DZ tip II și asociază nivele semnificativ mai crescute atât ale anxietăți, stare și trăsătură, cât și de depresie. Aceste rezultate ar putea constitui baza elaborării unor strategii de screening și de intervenție terapeutică la această categorie clinică de pacienți.Cuvinte cheie: personalitate D, diabet zaharat, calitatea vieții.

STUDY ON THE FREQUENCY OF TYPE D PERSONALITY AND ITS IMPACT ON THE QUALITY OF LIFE IN OUTPATIENTS WITH TYPE II DIABETES FROM TIMIS COUNTYObjectives. The current research aimed to identify the frequency of type D personality in outpatients with diabetes mellitus that are monitored and treated in Timis county. Also, several psychopathological factors significant represented in studied subjects were analyzed.Methods. A cross-sectional research was performed at Timisoara Diabetes, Nutrition and Metabolic Diseases Clinic in 79 subjects diagnosed with type II Diabetes Mellitus that were initially assessed. Exclusion criteria were represented by the existence of an already known and under treatment psychiatric disorder. The presence of type D personality was assessed by using DS-14 scale. Both trait and state anxiety were assessed with STAI-Y scale. Quality of life was quantified by using Q-LES-Q-SF scale (Quality of Life Enjoyment and Satisfaction Questionnaire). Depression was assessed using Beck Depression Inventory Version I. Data were statistically analyzed with SPSS version 17 for Windows.Results. Type D personality was very frequent in our research being identified in 38 of studied subjects

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(48,1%). Regarding the quality of life, studied subjects with both type D personality and type II diabetes mellitus have had significantly lower average scores at social relationships, daily life activity, sexual activity, physical state and work and hobbies domain (p < 0,05). Both state anxiety (t = 3,410; p = 0,001) and trait anxiety (t = 3,316; p = 0,001) have had significantly higher scores in subjects with type II diabetes mellitus and concurrent type D personality in comparison with those subjects with diabetes mellitus but without type D personality. Diabetic patients with type D personality have had significantly higher scores for depression in comparison with those without type D personality (t = 4,308; p < 0,001).Conclusions. The presence of type D personality interferes significantly and negatively with several domains of quality of life in patients with type II diabetes mellitus. Likewise, these patients have had higher scores for trait and state anxiety and for depression. These results should be taking into account in establishing a strategy for screening and therapeutic intervention in this particular category of patients.Keywords: diabetes mellitus, quality of life, type D personality.

I N T E R D E P E N D E N Ț A P S I H I A T R I E -LEGISLAȚIE. RAPORT

1 2Valentin Gheorghiu , Felicia Militaru1Universitatea de Medicină și Farmacie „Carol Davila, București, Romania2Universitatea de Medicină și Farmacie din Craiova, Romania

Introducere. Psihiatria medico-legală este un domeniu particular în sensul că folosește principiile psihopatologiei generale dar domeniul de activitate este în relație strânsă cu jurisprudența fiecărei țări. Această relație determină diferențe de abordare a managementului pacientului.Scop. Aprofundarea cunoștințelor privind noile coduri ale României cu accent în domeniul internărilor nonvoluntare.Discuții. În acest referat, autorul prezintă principalele reglementări legale care interferează atât activitatea psihiatrică generală cât și activitatea psihiatrico-medico-legală. 1. Se analizează regimul legal al internărilor nevoluntare din cele trei perspective:1.1. Internările nonvoluntare prevăzute de Legea Sănătății Mintale sunt strict reglementate; în această situație, sistemul judiciar are doar rol de control; se subliniază aspectele corelative clinice și legale din perspectiva respectării drepturilor omului și a reglementărilor internaționale în acest domeniu.1.2. Internările nonvoluntare prevăzute de Codul de Procedură Penală sunt relaționate ca activitatea de expertiză medico-legală psihiatrică. Se explică prevederile Noului Cod Penal.1.3. Internările nonvoluntare prevăzute de Codul Penal se relaționează cu periculozitatea socială a pacienților care au comis fapte penale și care nu sunt responsabili penal; se explică procedurile acestui tip de internări în relație cu respectarea drepturilor și libertăților persoanei . 2. Se discută prevederile legale privind punerea sub interdicție a bolnavilor psihici în acord cu normele legale

ale României și cu reglementările internaționale semnate de către România.Concluzii. Modificare Codurilor implică reevaluarea cunoștințelor psihiatrilor despre reglementările legale privind protecția bolnavilor psihici și respectarea drepturilor acestoraCuvinte cheie: Coduri Românești, internare nonvoluntară.

I N T E R D E P E N D E N C E P S Y C H I AT R Y – LEGISLATION. REPORTIntroduction. Forensic psychiatry is a particular area in that it uses principles of general psychopathology but this area is closely related to the jurisprudence of each country. This relationship determines the differences in approach to patient management.Scope. Increasing knowledge about the Romanian New Codes with an emphasis in non-voluntary admissionsDiscussions. In this paper, the author presents the main legal regulations that interfere both general Psychiatry and forensic psychiatric work.1. Analyse the legal regime of involuntary hospitalization of three perspectives:1.1. Non-voluntary admissions provided by Mental Health Act are strictly regulated; in this circumstances, the judiciary system has only watchdog role. There are explained clinical and legal correlative issues in terms of respecting human rights and international regulations in this area.1.2. Non-voluntary admissions of the Code of Criminal Procedure are related to the work of forensic psychiatry. It explains the new Criminal Code.1.3. Non-voluntary admissions under the Penal Code relates to the social dangerousness of patients who have committed crimes and who are not criminally responsible. There are explained procedures such admissions in relation to the rights and freedoms of individuals.2. There are discussed the legal provisions on restrictive alternative (custody) of mentally ill under the agreement with Romania's legal norms and international statutes signed by Romania.Conclusions. Changing Codes revaluation involves psychiatrists' knowledge about the legal regulations concerning the protection and respect for their mentally illKeywords: Romanian codes, non-voluntary admission.

PARTICULARITĂȚI ALE MANAGEMENTULUI BOLNAVULUI PSIHIC CU IMPLICAȚII PENALEGabriela CosteaInstitutul Național de Medicină Legală „Mina Minovici” București, Romania

Introducere. Asistența medicală psihiatrică al pacientului cu implicații penale se analizează pe două axe de abordare: axa medicală - psihiatrică generală și axa situației juridice. Din perspectiva asistenței medicale propriu-zise, managementul cazului implică standardele asistenței psihiatrice și managementul riscului. În acord cu jurisprudența românească asistența psihiatrică se acordă în închisori, în spitale de psihiatrie și pentru măsuri de siguranță și în ambulatoriu.Scop. Înțelegerea prevederilor Noului Codul Penal în raport cu bunele practici medicale și cu conceptele „medicina centrată pe persoană”, „medicina bazată pe

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dovezi”. Discuții. Se discută problematica discernământului și a periculozității sociale, metodologia expertizelor medico-legale psihiatrice pentru stabilirea discernământului.Există 2 mari categorii de pacienți psihici care au comis fapte penale: pacienți care au comis fapte penale cu discernământ (responsabili penal) și pacienți care au comis fapte penale fără discernământ (iresponsabili penal). Se prezintă o clasificare a pacienților condamnați, în funcție de antecedentele psihiatrice, expertizarea medico-legală psihiatrică și încadrarea în prevederile art. 109 C.P. Se detaliază diferențele de management a tuturor grupelor de pacienți cu referire la situația existentă la momentul preluării acestuia în contextul antecedentelor comportamentale și penale, a evoluției posibile și a recomandărilor medicale generale, psihiatrice, criminologice și socio-psihologice. Situațiile descrise sunt ilustrate cu cazuri.Concluzii. Se constată o subevaluare psihiatrică a pacienților condamnați. Se constată particularități in ”managementul cazului” la pacienții care au comis fapte penale. Se demonstrează necesitatea cunoașterii, de către toți psihiatri, a prevederilor legale privind activitatea psihiatrică, particularitățile managementului cazului și a bunelor practici medicale derivate din aceste particularități.Cuvinte cheie: pacienți condamnați, tratament psihiatric.

MANAGEMENT FEATURES OF THE MENTALLY ILL WITH CRIMINAL IMPLICATIONSIntroduction. Healthcare psychiatric patient with criminal implications are analyzed on two axes approach: medical axis - the axis of general psychiatry and legal situations. From the perspective of medical care themselves, the case management involves psychiatric Assistance Service standards and risk management. According to Romanian the jurisprudence Romanian, psychiatric assistance is granted in prisons, in Psychiatric and for Safety Measures Hospitals and to and for outpatients.Scope. Understanding the provisions of the New Criminal Code in relation to ”good medical practices” and concepts "person-centered medicine" ”evidence-based medicine".Discussions. It discusses issues of discernment and social dangerousness, forensic psychiatric expert methodology to determine competency.There are two major categories of psychiatric patients who have committed criminal offenses: patients who have committed criminal acts with discerning fate (criminal charge) and patients who have committed criminal acts with indiscriminately (criminally irresponsible). Patients who have committed crimes is presented a classification of convicted patients, according to psychiatric history, Forensic Psychiatric Expertise and the framed in art. 109 C.P. It details the differences in management of all groups of patients according to the situation at the time of its acquisition in the context of behavioral and criminal history, evolution and possible general medical, psychiatric, criminological and socio – psychological recommendations. The situations described are illustrated with casuistry.Conclusions. There is a psychiatric undervaluated of the convicted patient. It features found in "case management" in patients who have committed crimes. It demonstrates the need to know, by all psychiatrists, legal provisions

relating to psychiatric work, case management peculiarities and best medical practices derived from these features.Keywords: convicted patients, psychiatric treatment.

DILEMELE APLICĂRII PREVEDERILOR ART. 109 C.P.

1 2 3Gabriela Costea , Diana Bulgaru-Iliescu , Ion Udriștoiu1Institutul Național de Medicină Legală „Mina Minovici” București, Romania2Institutul de Medicină Legală Iași, Romania3Universitatea de Medicină și Farmacie din Craiova, Romania

Introducere. Codul Penal din România impune tratament obligatoriu ambulator la anumiți pacienți, printre care și la pacienți cu tulburări psihice. Nu se precizează criterii privind recomandările încadrării în acest articol de lege, deoarece criteriile de recomandare sunt strict medicale. Punerea în practică a acestei prevederi se lovește de dificultăți; unele dificultăți sunt de natură logistică; altele derivă din necunoașterea aprofundată a relației tratament obligatoriu – drepturile și libertățile persoanei – drepturile bolnavului psihic. Scop. Analiza situației de fapt a monitorizării bolnavilor psihici aflați sub prevederile art. 109 C.P.Discuții. Se discută în detaliu principiile prev. art. 109 C.P. , diferențele dintre ”pericol” și ”periculozitate” socială și diferențele dintre criteriile juridice și medicale ale acestor concepte. Autorii detaliază condițiile psihiatrice și juridice ale bolnavilor psihici încadrați în prev. art. 109 C.P. Se discută aspectele etice ale tratamentului bolnavului psihic. ”Managementul cazului” al bolnavului psihic încadrat în prevederile art. 109 C.P. este analizat din perspective multiple: patologia psihiatrică, problematica juridică, ținta propusă, condițiile practice medicale și sociale de monitorizare a tratamentului. Toate particularitățile sunt exemplificate cu cazuri. Lucrarea este concepută pe baza principiilor ”medicina centrată pe persoană”, ”medicina bazată pe dovezi”. Concluzii. Există dificultăți reale de aplicare a prev. art. 109 C.P. Este necesar a se stabili reguli de ”bune practici” în ceea ce privește asistența medicală a pacienților psihici încadrați în prev. art. 109 C.P. care să răspundă atât rigorilor medicale cât și cerințelor justiției. Cuvinte cheie: art. 109 C.P., tratament obligatoriu ambulatoriu.

APPLICATION DILEMMAS OF THE ARTICLE 109 - ROMANIAN PENAL CODE.Introduction. Romania Penal Code imposes mandatory outpatient treatment in some patients, including patients with mental disorders. No recommendations specified criteria for classification in this article of the law, because the recommendation criteria are strictly medical. Implementation of this provision runs into difficulties; some are logistical difficulties; others derive from ignorance depth relationship compulsory treatment - individual rights and freedoms - the rights of the mentally ill.Scope. Real situation analysis of monitoring fit to article 109 Penal Code.Discussions. It discusses in detail the principles. art. 109 Penal Code, the differences between "risk" and social

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"danger" and the differences between the legal and medical criteria of these concepts. The authors detail the medical and legal conditions of mentally ill employed in Article 109 C.P. It discusses the ethical issues of the treatment of mentally ill. It is analyzed the 'Case management' of the mentally ill employed in art. 109 P.C. from multiple perspectives: psychiatric pathology, legal issues, the target proposed and the practical conditions of medical and social treatment monitoring. All features are exemplified by casuistry. The work is designed based on "person-centered medicine", "evidence-based medicine".Conclusions. There are real difficulties of applying the provisions of Article 109 Penal Code. It is necessary to establish standards of "best practices" in terms of psychiatric care of the patients employed in art. 109 P.C. that meets both the medical assistance rigors for mentally ill and demands justice.Keywords: Article 109 HP, mandatory outpatient treatment.

FACTORI CARE POT INFLUNTA STAREA DE S Ă N Ă T A T E . C O M P O R T A M E N T D E AUTOVĂTĂMARE NONSUICIDARĂ

1 2Gabriela Costea , Ionela Bisu1Institutul Național de Medicină Legală „Mina Minovici” București, Romania2Spitalul Penitenciar Jilava, Romania

Introducere. Tulburările de conduită la copii și preadolescenți sunt frecvent relaționate cu deprivarea afectivă și cu comportamentul de autovătămare nonsuicidară a adultului. Literatura de specialitate românească și internațională evidențiază rolul factorilor nonmedicali care pot influența starea de sănătate a persoanei. Scop. Autorii doresc să demonstreze complexitatea vulnerabilității pacienților cu comportamente de autovătămare nonsuicidară.Material și metodă. Au fost examinați 140 de pacienți condamnați, internați în Spitalul Penitenciar Jilava – București. S-au studiat documentele medicale și documentaț ia medico-socială . S-au anal izat comportamentele de autovătămare nonsuicidară în raport cu vârsta debutului acestui comportament, condițiile debutului, factorii ce pot influența starea de sănătate conform codurilor ”Z” ale Clasificării Internaționale ale Maladiilor (CIM – 10) și motivația oferită de către pacient pentru debutul autovătămătii. S-a folosit programul SPSS pentru Windows. Rezultate și discuții. S-au constatat corelări între condițiile debutului comportamentului de autovătămare nonsuicidară și factorii ce pot influența starea de sănătate. Domină factorii de deprivare afectivă și condițiile de asistență protejată. Autorii delimitează grupe de factori și ierarhizează influența acestor factori. Fiecare situație este ilustrată cu afirmațiile pacientului.Concluzii. Nevoile acestui tip de pacienți sunt subevaluate. Rezultă că programele de asistență a acestora nu sunt eficace în ceea ce privește managementul vulnerabilităților psiho – sociale. Autorii consideră clasificările stării de sănătate și a calității vieții, recomandate de către Organizația Mondială a Sănătății, sunt incomplete și ineficiente în psihoprofilaxie și prevenție.

Cuvinte cheie: autovătămare, deprivare afectivăa.

FACTORS THAT MAY INFLUENCE HEALTH STATUS.NONSUICIDAL SELF-INJURY BEHAVIORIntroduction. Conduct disorders in children and preadolescents are frequently related to emotional deprivation and with adult non-suicidal self - injury behavior. Romanian and international literature emphasizes the role of non-medical factors that can influence the health of the person.Scope. The authors wish to demonstrate the complexity of the vulnerability of patients with non-suicidal self-injury behaviors.Material and method. 140 convicted hospitalized (in Jilava Penitentiary – Bucharest Hospital) patients were examined. There are studied the medical records and medical-social documentation. There are analyzed the non-suicidal self-injury behaviors in relation to age of onset of this behavior, the conditions of onset, factors that may influence health (according to the codes "Z" of the International Classification of Diseases / ICD - 10) and motivation offered by the patient for onset of non-suicidal. It used SPSS for Windows.Results and discussions. There are founded the correlations between the conditions of non-suicidal self-injury onset and the non-medical factors that influence mental health. Dominate emotional deprivation factors and negative health-protected conditions. The authors delimit groups of the factors and ranks the influence of these. Each situation is illustrated with patient statements.Conclusions. The needs of such patients are undervalued. It follows that their assistance programs are not effective in terms of managing psycho – social vulnerabilities. The authors consider classifications of the ”health status” and ”quality of life” recommended by the World Health Organization, are incomplete and ineffective for prevention.Keywords: self-harm, emotional deprivation.

ETICĂ, COMPETENȚĂ ȘI DISCERNĂMÂNT ÎN PSIHIATRIA GERIATRICĂ Nicoleta TătaruOradea, România

Psihiatrii trebuie să facă faţă la serioase provocări etice şi medicale în îngrijirea bolnavilor psihici vârstnici cu sau fără demenţă, până la sfârşitul vieţii, asigurându-le cea mai bună calitate a vieţii, pe cât este posibil.Odată cu creșterea numărului de vârstnici, va crește și prevalența demenței și problemele legate de competență și discernământ a acestor persoane.Societatea este interesată în menținerea autonomiei și a stării de bine a cetățenilor săi vârstnici și a protejării lor în fața riscurilor și pericolelor cauzate de declinul capacității lor și împotriva stigmei și discriminării. Bolnavii cu demenţă sau alte boli psihice sunt deseori neglijaţi, sau primesc o îngrijire sub-optimală. Ei pot deveni incapabili să își reprezinte interesele și să își administreze afacerile personale.Discutăm despre capacitatea mentală, competență globală și competențe specifice, precum și despre lipsa competenței datorită afecțiunilor mintale. Discernământ,

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responsabilitate şi competență devin importante în îngrijirea vârstnicilor cu boli mintale, consimțământ informat în cercetare şi acceptarea tratamentului, în stabilirea tutelei, curatelei şi a veridicităţii testamentului la bolnavii non-competenți. Apar probleme când aceşti pacienţi sunt singuri sau sunt în conflict de interese cu familia sau cei care îi îngrijesc și alte persoane trebuie să răspundă și să decidă in favoarea celor bolnavi. Apar astfel dileme etice în îngrijirea acestor bolnavi cu sau fără demență.Cuvinte cheie: etică, geriatrie, îngrijire.

ETHICS AND CAPACITY IN OLDER PEOPLE WITH MENTAL DISORDERSAfter a short review of ethical aspects of care for elderly mentally ill with or without dementia, we discuss about psychiatric assessment of their capacity or competence and about involuntary treatment of incompetent patients. With the increasing prevalence of dementia, issues of competency have become very important. Society is interested in maintaining the autonomy and well-being of its aging citizens and to protect them from risks and dangers caused by their declining capacities. The psychiatrist should discuss with their legal counsel in order to safeguard the legal rights of the patient when he/she is unable to exercise proper judgment due to mental disorder. Some of our patients, particularly older people with dementia, may not be able effectively to represent their interests and manage their affairs.We discuss about the mental capacity and global and specific competence and also about the non-competence due to mental disorders, especially dementia. The incompetent person cannot understand, appreciate and decide on specific issues of one's daily life. When the patient is non-competent or partially non-competent the others should make the decisions on his behalf.Older people with mental disorders are particularly vulnerable to neglect and abuse, they may experience the double jeopardy of stigmatization due to psychiatric illness and due to being old. In some clinical situations, a conflict between different ethical principles may occur, and professionals and caregivers need to be aware of this and to be guided about how to behave.Keywords: ethics, geriatrics, care.

BOALA PSIHOSOMATICĂ. PROFILE DE P E R S O N A L I TAT E Ș I D I A G N O S T I C E PSIHIATRICE ADIACENTE

1 2 3 3Simona Trifu , Diana Onilă , Anca Gutt , George Negru1Universitatea de Medicină și Farmacie „Carol Davila” București, Romania2Cabinet Individual de Psihologie București, Romania3Spitalul de Psihiatrie Săpunari, Romania

Motivația alegerii temei de cercetare. Conceptul de boală psihosomatică a fost actualmente extins și se caută în medicina allopată componenta de stress adiacentă fiecărei boli somatice.Obiective. Lucrarea de față investighează un număr mare de pacienți (peste 300) internați în diferite clinici de Medicină Internă cu diagnostice considerate psihosomatice și pensionați medical pe caz de boală. Dorim să reliefăm diferite componente psihologice care

alcătuiesc generic mecanismele de coping ale celor în cauză, cât și asocierea clinică a unui diagnostic psihiatric la un procent semnificativ din cei investigați.Ipoteză. Cercetarea cuprinde șase ipoteze legate de: tensiunea interioară, factorul social, afilierea, climatul de exprimare a emoțiilor, asocierea simptomelor manifeste din sfera depresiei și utilizarea unor stiluri defensive dezadaptative ca factori ce influențează profilul de exprimare al unei boli psihosomatice.Metode. Administrarea chestionarelor de personalitate CAQ (scale clinice și neclinice), DSQ (pentru stiluri adaptative de coping), interviu centrat pe identificarea factorilor definiți în ipoteze, analiză statistică de tip test T, analiză factorială, rotație factorială Varimax cu normalizare Kaiser.Rezultate. Profilul bolnavului psihosomatic are drept trăsături centrale: tensiunea, insecuritatea, nevoia de a primi aprobarea celorlalţi, respectiv aspecte din sfera anxietăţii şi dependenţei şi a unui coping dezadaptativ şi în mai mică măsură aspecte ce vizează independenţa, stabilitatea emoţională şi copingul adaptativ. La pacienţii psihosomatici, orice factor / trăsătură care încurajează exprimarea emoţională şi agresivitatea reies ca fiind sanogene, întrucât reduc tensiunea (anxietatea și frustrarea). Concluzii. Se confirmă ipoteza în conformitate cu care Tensiunea, în calitate de caracteristică de bază din profilul bolnavului psihosomatic manifestă o sensibilitate marcată la influenţa factorilor sociali, de mediu și economici, fapt ce poate amplifica pulsiunile suicidare. Corolar, se confirmă şi ipoteza conform căreia Stilurile defensive mai puţin adaptative precum DSQ imagine distorsionată de sine şi DSQ autosacrificiu sunt extrem de sensibile la influența factorilor de mediu, sociali și economici, potenţând exprimarea unui nou puseu de boală psihosomatică. Cuvinte cheie: boală psihosomatică, profil de personalitate, diagnostic psihiatric adiacent, stil de coping dezadaptativ.

PSYCHOSOMATIC DISORDER. ADJOINING P S Y C H I A T R I C D I A G N O S T I C S A N D PERSONALITY PROFILESMotivation: The actual concept of psychosomatic disorder has been extended, searching in allopath medicine the adjoining stress part of each somatic disorderObjective: This paperwork investigates a high number of patients (over 300) admitted in various clinics of Internal Medicine with medical diagnostics that is considered as a psychosomatic diagnostic being retired on case of sickness. We will show various psychological aspects that are generically under the name of coping mechanisms and also the clinical association with a psychiatric diagnostic (on 91.75% of them) Hypothesis: Based on 6 factors linked to: inner tension, social factor, affiliation, external climate for expressing the emotions, association of symptoms from the area of depression and the use of non-adaptive defensive mechanisms - they influence the psychosomatic profile of the disorder. Method: CAQ (clinical and non-clinical scales), DSQ (for adaptive coping styles), clinical interview centered to identify above mentioned factors, statistical analysis type T, factorial analysis, Varimax factorial rotation with

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Kaiser normalization Results: The profile of the patient with a psychosomatic disorder is centered on: tension, insecurity, the need for other's approval and also aspects from anxiety and dependency area together with non-adaptive coping; in a smaller manner it sees the independence, emotional stability and adaptive coping. On these patients, any factor/aspect that encourage the emotional expression and aggressiveness are considered as sanogenousConclusion: The tension as a base characteristic of a psychosomatic patient is highly sensitive to social and economic factors, fact that can increase the suicide compulsion. Defensive styles less adaptative as distorted image (DSQ) and self-sacrifice (DSQ) are also highly sensitive to social and economic environment, potentiating a new sudden occurrence of psychosomatic disorder.Keywords: psychosomatic disorder, personality profile, adjoining psychiatric diagnostics, non-adaptive coping style.STUDIU PROSPECTIV PRIVIND ASPECTE ALE PERSONALITĂȚII ȘI PSIHOPATOLOGICE ASOCIATE CU RISCUL DE APARIȚIE A DEPRESIEI POST-PARTUM LA UN LOT DE MAME CARE AU NĂSCUT ÎN JUDEȚUL TIMIȘ

1 1Virgil-Radu Enătescu , Marius Craina , Adrian 1 1 1Gluhovschi , Ion Papavă , Radu Romoșan , Ileana

1 1 2 1Enătescu , Oana Balazs , Virgil Enătescu , Elena Bernad 1Universitatea de Medicină și Farmacie “Victor Babeș” Timișoara, Romania2Ambulatorul de Psihiatrie a „Clinicii West Medica” Satu Mare, Romania

Obiective. Cercetarea de față a avut ca obiectiv principal atât evaluarea frecvenței depresiei perinatale (ante- și post-partum) la un lot de mame care au născut la nivelul județului Timiș cât și identificare acelor factori de personalitate și psihopatologici ce au crescut semnificativ riscul de apariție pentru depresia post-partum. Material și metodă. A fost efectuată o cercetare prospectivă în clinica și Ambulatorul de obstetrică a Clinici “Bega” Timișoara, care a inclus inițial la prima evaluare 118 gravide în perioada ante-partum. Dintre acestea, 80 au participat și la o a doua evaluare în perioada dintre săptămânile 6 – 8 post-partum. Pentru depresia perinatală a fost utilizat un prag de > 13 în Scala. Edinburgh pentru Depresie Postnatală. Anxietatea atât stare cât și trăsătură a fost evaluată cu scala STAI-Y iar personalitatea a fost evaluată dimensional cu chestionarul NEO-FFI bazat pe modelul five-factor. A fost realizată o analiză prin regresie lineară multiplă a variabilelor care s-au corelat semnificativ cu scorurile de depresie post-partum.Rezultate. Vârsta medie a lotului inițial a fost de 28,64 ani (D.S. = 5,626). Prezența depresiei ante-partum a fost consemnată la 21 de gravide (N=118; 26,2%) și post-partum la 28 mame (N=80; 8,8%). Dintre mamele care au refuzat să participe la a doua evaluare 7 (N=38; 18,4%) aveau depresie ante-partum. Anxietate stare ante-partum (r = 0,350; p = 0,001), anxietatea trăsătură ante-partum (r = 0,239; p = 0,033), anxietatea stare post-partum (r = 0,378; p = 0,001), anxietate trăsătură post-partum (r = 0,377; p = 0,001) și nevrotismul (r = 0,269; p = 0,016) s-au corelat semnificativ cu scorurile de depresie post-partum. În urma analizei prin regresie lineară multiplă doar anxietatea

trăsătură post-partum (Beta standardizat = 0,576) și anxietatea stare post-partum (Beta standardizat = 0,244) s-au asociat semnificativ cu riscul de apariție a depresiei post-partum (R2 = 0,557; p = 0,011).Concluzii. Prezența depresiei perinatale este un aspect psihopatologic extrem de reprezentativ la mamele care au născut la nivelul județului nostru în toată perioada perinatală dar mai ales ante-partum. Anxietatea atât stare cât și trăsătură au avut putere de predicție asupra riscului crescut de apariție a depresiei post-partum iar de acest rezultat are trebui să se țină cont în construirea strategiei de intervenție terapeutică pentru aceste mame.Cuvinte cheie: depresia post-partum, personalitate, psihopatologie

PROSPECTIVE STUDY ON PERSONALITY AND P S Y C H O P A T H O L O G I C A L A S P E C T S ASSOCIATED WITH THE OCCURRENCE RISK OF PERINATAL DEPRESSION IN A MOTHER'S SAMPLE WHO GAVE BIRTH IN TIMIS COUNTYObjectives. The current research mainly aimed both to detect the frequency of perinatal depression in mothers who gave birth in Timis county and to identify those personality and psychopathological factors that increased the risk of occurrence for post-partum depression.Methods. A prospective survey was conducted in the inpatient and outpatient units of “Bega” Clinic Timisoara in initially 138 women being monitored during their antepartum period. Of these, 80 women attended to the second assessment between 6 to 8 weeks of their postpartum period. Postnatal depression was assessed by Edinburgh Postnatal Depression Scale using a cut-off > 13. Both anxiety as a state and as a trait were assessed by STAI-Y scale. Personality was assessed by using NEO-FFI Inventory that is five-factor model based. A multiple linear regression analysis on significantly correlated variables was done.Results. The mean age in baseline sample was 28,64 years (S.D. = 5,626). The presence pf antepartum depression was noted in 21 women (N=118; 26,2%) and 28 new mothers (N=80; 8,8%) respectively. Of the mothers who refused to attend to the second assessment 7 (N=38; 18,4%) had antepartum depression. Antepartum state anxiety (r = 0,350; p = 0,001), antepartum trait anxiety (r = 0,239; p = 0,033), postpartum state anxiety (r = 0,378; p = 0,001), postpartum trait anxiety (r = 0,377; p = 0,001) and Neuroticism (r = 0,269; p = 0,016) significantly correlated with postpartum depression scores. As a result of multiple linear regression analysis only postpartum trait anxiety (Beta standardized = 0,576) and postpartum state anxiety (Beta standardized = 0,244) has significantly associated with the risk of postpartum depression occurrence (R2 = 0,557; p = 0,011).Conclusions. The presence of perinatal depression is an extremely representat ive psychopathological phenomenon in women delivering in our region, especially in antepartum period. Both anxiety as a state and as a trait have had prediction value on the occurrence risk of postpartum depression. This result should be taken into account in elaborating og therapeutic strategy for these women.Keywords: postpartum depression, personality, psychopathology.

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I N T E R V E N Ț I A P S I H I A T R I C Ă Ș I PSIHOTERAPEUTICĂ ÎN RECUPERAREA PACIENTULUI CU AFECȚIUNE CEREBRALĂ POSTTRAUMATICĂ

1 2 1George Negru , Simona Trifu , Anca Gutt , Daniela 1Brăileanu

1Spitalul de Psihiatrie Săpunari, Romania2Universitatea de Medicină și Farmacie „Carol Davila” București, Romania

Introducere. Contuzia temporo-occipitală soldată cu hematom intracerebral, având ca manifestare psihică instalarea simptomatologiei demenței posttraumatice, este o provocare pentru orice echipă terapeutică. În vederea obținerii unui rezultat pozitiv este necesară coordonarea intervenției farmacologice cu cea psihologică.Obiective. Diferențierea și izolarea simptomelor psihiatrice de cele neurologice, în vederea reducerii simptomatologiei psihiatrice, creșterea funcționalitații globale, precum și prevenirea și diminuarea riscului de suicid.Ipoteză. Simptomatologia psihiatrică este direct legată de dimensiunea hematomului intracerebral, de aceea administrarea tratamentului neurologic este esențială în potențiala recuperare psihiatrică. Stimularea cognitivă, senzorială si emoțională permanentă fac parte din procesul de recuperare si vor îmbunătăți rezultatele terapeutice, prin creșterea complianței la tratament, prin menținerea alianței terapeutice, precum și prin redobândirea insight-ului.Rezultate. Administrarea tratamentului medicamentos, atât neurologic, cât și psihiatric, împreuna cu intervenția ps iho log ică z i ln ică , au redus semnif ica t iv simptomatologia psihiatrică. Sechelele psihiatrice posttraumatice sunt minore, înțelese de pacientă si integrate corect, în vreme ce funcționalitatea globală se apropie de cea premergătoare traumatismului cranio - cerebral.Concluzii. Coordonarea si colaborarea dintre intervenția farmacologică si cea psihoterapeutică este esențială în recuperarea pacientului cu simptomatologie psihiatrică posttraumatică. Suportul familial si social își aduc, de asemenea, aportul, semnificativ, în continuarea recuperării post-externare și în continuarea programului de menținere sau îmbunătățire a funcționalității globale.Cuvinte cheie: Traumatism cranio-cerebral, demență posttraumatică, intervenție farmacologică, intervenție psihologică.

PSYCHIATRIC AND PSYCHOTHERAPEUTIC INTERVENTION FOR BRAIN DISORDER POST-TRAUMATIC RECOVERYIntroduction. temporal-occipital contusion resulting intracerebral haematoma, having as a psychiatric symptomatology post-traumatic dementia, it is a challenge for any therapeutic team. For a positive result it is necessary to coordinate pharmacological and psychological intervention.Objectives. The differentiation and isolation of psychiatric symptoms of the neurological ones, in order to reduce the psychiatric manifestation, increasing global functioning and preventing the suicide risk.Hypothesis. Psychiatric symptoms are direct related to the

dimension of the intracerebral haematoma, therefore the neurological medication is essential in psychiatric recovery. Cognitive, sensory and emotional permanent stimulation are an important part of rehabilitation process and will improve the therapeutic results by a better compliance and therapeutic alliance, also getting the insight over the issue.Results. Following administration of medication – neurological and psychiatric, along with daily psychological intervention, the psychiatric symptoms are considerable reduce. Psychiatric posttraumatic sequelae are minor, fully integrated by the patient, global functionality are close to the one prior the head trauma.Conclusions. Coordination and collaboration between pharmacological and psychological intervention was essential for rehabilitation of posttraumatic symptoms. Family and social support brings also an important contribution regarding post-hospitalization rehabilitation program.Keywords: head trauma, posttraumatic dementia, psychological intervention, pharmacological treatment.

PIERDEREA ACUITĂȚII AUDITIVE, FACTOR DETERMINANT ÎN APARIȚIA TULBURĂRILOR PSIHICEAneta Maria Tudose, Anca GuttSpitalul de Psihiatrie Săpunari, Romania

Motivația alegerii temei de cercetare. Pierderea sau scăderea unuia dintre simțuri aduce cu sine o succesiune de modificări ale altor abilitați înnăscute sau dobândite, iar când acesta este auzul, lucrurile devin mai complexe. Pentru pacientul în cauză, ca urmare a unei otomastoidite bilaterale, operate în cele din urma, se instalează treptat simptomatologia psihiatrică în formă acută.Obiective. Hipoacuzia dobândită, însoțită de tulburările de limbaj asociate, peste care se suprapune și hipertiroidismul, au condus în cazul de față la o Tulburare din spectrul axios, cu manifestări somatice în cadrul atacurilor de panică. Stabilirea schemei terapeutice, precum și implicarea într-un program de consiliere psihologică, conduc la o mai bună înțelegere a mediului si la creșterea funcționalității globale.Ipoteză. Deficiența de auz poate conduce către apariția fenomenologiei psihotice, de aceea este importantă depistarea cauzei declanșării atacurilor de panica, filon pe care îl presupunem a fi din spectrul psihotic, în încercarea pacientei de a umple golurile din informațiile percepute. Fondul de personalitate dependentă accentuează simptomatologia, determinând luarea în discuție a unui diagnostic diferențial de Tulburare factică. De aceea, alături de importanța creșterii stimei de sine, se impune controlul medicamentos al simptomatologiei psihiatrice.Rezultate. Schema terapeutică a inclus: tratament medicamentos, consiliere și intervenție psihologică, în sensul în care pacientei nu i s-au alimentat tendințele dependento-factice, primind tratament egal cu ceilalți pacienți. Simptomatologia se îmbunătățește semnificativ, urmând ca aceasta sa rămână în monitorizare psihiatrică si psihologică până la remitere.Concluzii. Modificarea funcționalității simțurilor aduce după sine o Schimbare durabilă de personalitate, precum și accentuarea unor trăsături de personalitate, mai ales în cazul în care pacienta se încadra într-unul dintre clustere,

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anterior instalării deficienței. Cuvinte cheie: hipoacuzie, hipertiroidism, Tulburare de panică, Schimbare durabilă de personalitate.

T H E L O S S O F H E A R I N G A C U I T Y , D E T E R M I N I N G F A C T O R I N T H E DEVELOPMENT OF MENTAL DISORDERTheme motivation. Loss or decrease of one of the senses causes a series of changes to inborn or acquired abilities, when we talk about the hearing the issues become more complex. Following a bilateral otomastoiditis, ultimately surgically corrected, psychiatric symptoms starts gradually to manifest. Objectives. Hearing loss along with speech disorder, with an overlapping of hyperthyroidism, had led to an anxiety disorder, with somatic manifestation following panic attacks. Setting of the therapeutic scheme and starting of a psychological counseling will lead to a better understanding of the environment and increase the global functioning of the patient. Hypothesis. Hearing impairment can cause the appearance of psychotic phenomenology; therefore, it is important to find the triggering of panic attacks, which we supposed to be from psychotic spectrum in an attempt to fill the gaps of the received information. The background of dependent personality worsens the symptoms and raise the question for factitious disorder as differential diagnosis. Therefore, it is important to work to self-esteem improvement and pharmacological controlling of psychiatric symptoms. Results. Therapeutically intervention had included: pharmacological treatment, psychological counselling and psychological intervention by not empower the patient's dependent-factitious disposition, being treated as the rest of the patients. Symptomatology get improved, the patient to remain in psychiatric and psychological observation until full recovery.Conclusions. The alteration of senses functionality brings up sustainable personality modification, especially if the patient fit in to the one of the clusters, prior deficiency. Keywords: hearing loss, panic attack, personality disorder.

I M PA C T U L P S I H I AT R I C O - L E G A L A L INFRACȚIUNILOR SEXUALE ÎNDREPTATE ÎMPOTRIVA MINORILOR ÎN REPUBLICA MOLDOVA Constanța Madan, Jana Chihai USMF „Nicolae Testemițanu” Chișinău, Republica Moldova

Infracțiunea sexuală reprezintă una dintre cele mai grave atingeri, atât în plan fizic, psihologic cât și în plan moral, pe care o poate suferi o persoană, indiferent de sex sau vârstă. Fapta este mult mai gravă atunci când victima acestui abuz este un copil, alterând procesul de formare psiho-socială a acestuia. Așadar, infracțiunea sexuală îndreptată împotriva copiilor a fost, este și va fi o problemă actuală și destul de dureroasă pentru societatea în care trăim și merită atenție și o abordare destul de serioasă. Actuala cercetare are drept scop studierea și relevarea structurii infracțiunilor sexuale îndreptate împotriva minorilor din Republica Moldova și rezultatul urmărilor psihiatrice evidente. Studiului au fost supuse și

analizate 100 de cazuri de infracțiuni sexuale îndreptate împotriva minorilor, cercetate în secţia clinică a Centrului de Medicină Legală din municipiul Chisinău, din perioada anilor 2010-2015. Ulterior au fost căutate numele acestor victime în fișele medicale din arhiva Spitalului Clinic de Psihiatrie, în vederea stabilirii prezenței unor tulburări psihice. S-a stabilit impactul infracțiunii sexuale asupra stării psihice a minorilor în funcție de: vârsta, sex, mediul de reședință, relația victimei cu agresorul, prezenţa leziunilor, gradul de gravitate a leziunilor prezente, clinica dezvoltată ulterior, debutul maladiei, diagnosticul stabilit, severitatea și decurgerea bolii, folosind o fișă-schemă statistică anexată.Cuvinte cheie: infracțiune sexuală, impact psihiatric, tulburare psihică, abuz.

T H E F O R E N S I C A N D P S Y C H I AT R I C CONSEQUENCES OF THE SEXUAL OFFENSES AGAINST THE MINORS FROM THE REPUBLIC OF MOLDOVA Sexual offense is one of the most severe harm, both physically and psychologically that may suffer a person, regardless of sex or age. The deed is more serious when the victim is a child, affecting its development. So sexual offense against children has been, is and will be an ongoing problem and quite painful for our society and deserves a serious enough approach. The research purpose is to study and reveal the structure of sexual offenses against minors in Moldova with obvious psychiatric consequences. 100 cases of sexual offenses against children examined at Clinical Department of Forensic Medical Center and at the Archive of the Psychiatric Hospital from Moldova were studied, during the period of 2010-2015 It was established the impact of the sexual abuse to minors according by age, sex, area of residence, the relationship between victim and aggressor, the presence of lesions, the seriousness of the injuries, diagnosis, the onset disease, frequency of admissions and discharges in Psychiatric Hospital using a annex statistics. Keywords: sexual offense, psychiatric track, mental disorder, abuse.

IMPACTUL BOLILOR CARDIOVASCULARE COMORBIDE TULBURĂRII DEPRESIVE UNIPOLARE

1 1 2George Bădescu , Daniela Glăvan , Mădălina Ovreiu , 2 2 2Maria Pănescu , Alexandra Hromei , Mădălina Fâlfan ,

2Dragoș Vulcănescu1Universitatea de Medicină și Farmacie din Craiova, Romania2Clinica de Psihiatrie II Craiova, Romania

Introducere. Tulburarea depresivă joacă un rol important în patologia cardiovasculară constituind atât un factor de risc pentru apariție cât și un factor de prognostic defavorabil. Principalele comorbidități cardiovasculare ale depresiei sunt reprezentate de: hipertensiunea arterială, infarctul miocardic, boala coronariană, insuficiența cardiacă. Metodă. Studiul clinic retrospectiv a fost efectuat pe un lot de 5054 de pacienți internați în spitalul clinic de Neuropsihiatrie Craiova cu diagnosticul de tulburare depresivă unipolară în intervalul 1 ianuarie 2008-31

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decembrie 2012 analizând ca și comorbidități bolile cardiovasculare.Rezultate. Dintre pacienții care au prezentat diagnostice multiple (psihiatric si somatic) cei mai mulți au fost cu o singură comorbiditate sau două boli somatice asociate, bolile cardiovasculare fiind cele mai des întâlnite comorbidități somatice ale pacienților diagnosticați cu tulburare depresivă unipolară. Comorbiditățile cardiovasculare (hipertensiunea arterială, infarct miocardic, boala coronariană, insuficiența cardiacă) au fost menționate în documente medicale pentru 1923 de pacienți din lotul total de 5054 de pacienți studiați . S-a observat că ponderea pe sexe a comorbidităților cardio-vasculare în tulburarea depresivă unipolară este mai crescută la femei. A fost remarcată o durată medie a internărilor mai mare la pacienții care nu au asociat comorbidități somatice comparativ cu cei la care simptomatologia depresivă și somatică s-a manifestat concomitent.Concluzie. Asocierea comorbidității cardiovasculare la pacientul cu tulburare depresivă unipolară conduce la amplificarea efectului dizabilitant. Comorbiditatea cardiovasculară, sexul feminin, grupa de vârstă 45-64 ani, mediul urban de rezidență se asociază înalt semnificativ cu evoluția defavorabilă a tulburării depresive unipolare fiind tradusă prin creșterea numărului de internări și a duratei acestora, ceea ce impune un management terapeutic diferențiat și multidisciplinar. Cuvinte cheie: tulburare depresivă, comorbidități cardio-vasculare, factori de risc.

T H E I M P A C T O F C O M O R B I D CARDIOVASCULAR DISEASES ON UNIPOLAR DEPRESSIVE DISORDERBackground. Depressive disorder plays an important role in cardiovascular disease, is both a risk factor and unfavorable prognostic factor. Major comorbidities of depression are represented by hypertension, myocardial infarction, coronary artery disease, heart failure.Method. Retrospective clinical study was conducted on a sample of 5054 patients hospitalized in the University Clinic of Neuropsychiatric Craiova diagnosed with unipolar depressive disorder between 1 January 2008 - December 31 2012 as comorbidities analyzing cardiovascular diseases.Results. Among patients who had multiple diagnoses (psychiatric and somatic) most were one or two comorbid somatic diseases associated, cardiovascular diseases were the most common somatic comorbidities of patients diagnosed with unipolar depressive disorder.Cardiovascular comorbidities (hypertension, myocardial infarction, coronary heart disease, heart failure) have been mentioned in medical records for 1923 patients in total group of 5054 patients studied. It was found that the percentage of male and female cardiovascular comorbidities in unipolar depressive disorder is higher at women. It was noticed a higher average duration of admissions in patients who have associated somatic comorbidities compared to those that depressive symptoms and somatic was shown simultaneously.Conclusion. The association of cardiovascular comorbidities in patient with unipolar depressive disorder leads to amplification debilitating effect. Cardiovascular comorbidity, female gender, age group 45-64 years, urban

residency significantly associated with unfavorable evolution of unipolar depressive disorder being translated by increasing the number of hospitalizations and their durat ion, which requires differentiated and multidisciplinary therapeutic management.Keywords: depressive disorder, cardiovascular comorbidities, risk factors.

ROLUL PATOGENIC AL MODIFICĂRII RAPORTULUI NEURON-ASTROGLIE ȘI A UNITĂȚII NEUROVASCULARE ÎN BOALA ALZHEIMERTudor Udriștoiu, Dragoș Marinescu, Ileana Marinescu, Felicia Militaru, Ion UdriștoiuUniversitatea de Medicină și Farmacie din Craiova

Incidența crescută a bolii Alzheimer impune modificarea strategiilor terapeutice în baza descifrării mecanismelor patogenice ale acestei afecțiuni. Dacă până în urmă cu aproximativ un deceniu conceptul patogenic al neurodegenerescenței domina, rolul determinant fiind acordat depunerii de betaamiliod și a modificărilor neurofibrilare, în momentul actual acordată o importanță deosebită modificării raportului între neuron și astroglie.Studiile fundamentale au scos în evidență apariția modificărilor la nivelul substanței albe, cu aproximativ 15 ani anterior depunerii primelor plăci de betaamiloid. Modificările substanței albe au putut fi identificate prin tehnici neuroimagistice evidențiindu-se hiperintensități la acest nivel, iar acestea au fost corelate semnificativ cu prezența tulburării depresive. În acest context, s-a evidențiat faptul că patogeneza multisistemică a depresiei care implică creșterea factorilor proinflamatori, a disfuncției endoteliale și a activărilor citokinice și a celor microgliale, pot fi un factor de risc pentru scăderea raportului neuron-astroglie. Hiperactivitatea neuronală deprivată de suportul metabolic astrocitar determină activări glutamatergice cu mecanisme de tip excitotoxic reglate de balanța neurobiochimică între sistemul acetilcolinic și glutamat prin intermediul receptorilor de tip NMDA (hiperactivați) și a receptorilor muscarinici și nicotinici (inhibați).Modificarea raportului neuron-astroglie și mecanismele plurigenetice descrise anterior pot altera funcționalitatea unității neurovasculare cu hipoperfuzie cerebrală care la rândul său agravează mecanismele de tip apoptotic. Se poate concluziona că tulburarea depresivă anterioară diagnosticului de boală Alzheimer, constituie un factor de risc important, favorizând alterarea funcțională și structurală a circuitelor cognitive cortico-subcorticale.Cuvinte cheie: boala Alzheimer, hiperintensități, hiperactivitate NMDA, tulburare depresivă.

THE PATHOGENIC ROLE OF ALTERING THE NEURON-ASTROGLYA RAPPORT AND THE NEUROVASCULAR UNIT IN ALZHEIMER'S DISEASEThe increased incidence of Alzheimer's Disease triggers the change of therapeutic strategies based on the understanding of the pathogenic mechanisms of this disorder. If until a decade ago, the dominant concept was the neurodegeneration with beta-amyloid deposits and neurofibrillar alterations, nowadays the attentions switched to the alteration of the rapport neuron-astroglia.

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The fundamental research showed the alterations in the white matter 15 years before the identification of the first deposits of betaamyloid. The changes of the white matter were identified with neuroimagistic techniques showing hyperintensities that were significantly correlated with the presence of depressive disorder. Within this frame, it has been assumed that the multisystemic pathogenesis of depression with the increase of pro-inflammatory factors, endothelial dysfunction and activation of cytokines and microglia may be a risk factor for the reduction of the neuron-astroglia rapport. The neuronal hyperactivity deprived of the astrocyte's metabolic support generates glutamatergic activations with excito-toxic mechanisms that are regulated by the neurobiochemical balance between the acetylcholine and glutamate systems through NMDA receptors (hyperactivated) and muscarinic and nicotinic receptors (inhibited).The alteration of the neuron-astroglya raport and the plurigenetic mechanisms mentioned above may alter the functionality of the neurovascular unit with cerebral hypoperfusion that in turn aggravates the apoptotic mechanisms. We may conclude that depression disorder prior to the diagnosis of Alzheimer' Disease is a significant risk factor that favors the functional and structural alteration of the cortico-subcortical cognitive circuits.Keywords: Alzheimers' Disease, hyperintensities, NMDA hyperactivity, depressive disorder

PATOLOGIA PSIHIATRICĂ MAJORĂ – ABORDARE SISTEMICĂ ȘI APLICAȚII PRACTICE

1 2Gabriela Costea , Felicia Militaru1Institutul Național de Medicină Legală „Mina Minovici” București, Romania2Universitatea de Medicină și Farmacie din Craiova, Romania

Introducere. Patologia psihiatrică majoră se analizează, teoretic, din perspective multiple. Din punct de vedere aplicativ, precizarea conceptelor teoretice care stau la baza ”managementului cazului” este importantă mai ales la pacienții ”speciali” (exemplu: pacienții cu implicații penale, pacienții cu comorbidități somatice multiple). Abordarea sistemică este mai puțin folosită dar este de un real ajutor în situații particulare și în rezolvarea problemelor etice. Scop. Necesitatea cunoașterii etapelor de analiză sistemică a pacienților cu patologie psihiatrică majoră. Discuții. Lucrarea este teoretică, argumentată prin cazuistică. S-au trecut în revistă, din perspectivă clinico-statistică și evoluționist-fenomenologică, câteva aspecte ale pacienților internați în clinica de psihiatrie Craiova, într-o perioadă de un an. S-au analizat, din perspectivă fenomenologică, câteva cazuri de pacienți care au comis fapte penale, fiind iresponsabili penal. Din perspectivă sistemică, s-au analizat câteva cazuri de pacienți cu nevoi speciale. S-au analizat, la fiecare grupă de pacienți, țintele comune ale asistenței medicale. S-au apreciat elementele comune și diferențele în ceea ce privește managementul terapeutic precum și dilemele etice ce pot apare pe parcursul asistenței medicale complexe.Concluzii. Indiferent de conceptele teoretice abordate, în final, se realizează o reducție clinică cu implicații terapeutice. Managementul terapeutic adecvat și

reabilitatea socială presupun o abordare complexă a pacientului psihic cu patologie majoră. Viziunea antropologică asupra psihopatologiei prezintă interese pentru patologia psihiatrică majoră. Viziunea complexă de tip antropologic și sistemic apare importantă la pacienții cu patologie psihică majoră și nevoi speciale; această abordare rezolvă și eventuale dificultăți de tip etic și deontologic. Cuvinte cheie: concept sistemic, psihoze, schizofrenie.

MAJOR PSYCHIATRIC PATHOLOGY – SYSTEMIC APPROACH AND PRACTICAL APPLICATIONSIntroduction. Major psychiatric pathology is analyzed theoretically from multiple perspectives. In terms of application, specifying the theoretical concepts underlying "case management" it is especially important in patients 'special' (e.g. patients with criminal implications, patients with multiple comorbid somatic). The systemic approach is less common but is helpful in particular situations and in resolving ethical issues.Purpose. The need to know the stages of systemic analysis of patients with major psychiatric pathology.Discussions. The workpaper is theoretical, argued by casuistry. There are reviewed, by clinical - statistics and evolutionary – phenomenological perspectives, some aspects of inpatient psychiatric clinic in Craiova, into period of one year. They were analyzed from a phenomenological perspective, several cases of patients who have committed crimes (criminal irresponsible). From a systemic perspective, were analyzed several cases of patients with special needs. They looked at each group of patients, the common targets of mental healthcare. They appreciated the commonalities and differences in the therapeutic management and ethical dilemmas that may occur during complex healthcare.Conclusions. Regardless of the theoretical concepts addressed, a clinical reduction with therapeutic implications is achieved finally. Social rehabilitation and an appropriate therapeutic management are involved a comprehensive approach to patient with mental pathology major. Anthropological vision of psychopathology presents interest for major psychiatric pathology. Anthropological and systemically complex vision occurs (like important) in patients with major mental pathology and special needs. This approach solves any type of ethical difficulties.Keywords: systemic concept, psychosis, schizophrenia. PSEUDODEMENȚA - O VARIANTÃ A DEPRESIEILavinia Duică, Luiza ZamfirescuUniversitatea “Lucian Blaga” Sibiu, Romania

Pseudodemența depresivă este o condiție psihopatologică pe care o întâlnim uneori în practica clinică la persoane vârstnice. Aceasta constă în prezența simptomelor cognitive marcate care sunt cauzate de fapt de depresie.Pacienta V.I, în vârstă de 60 de ani, cunoscută cu antecedente psihiatrice, s-a prezentat cu următoarele simptome: dispoziție depresivă, anxietate, vagi elemente paranoide, tulburări de concentrare și de memorie. Simptomatologia a debutat în urmă cu aproximativ 2 ani în urma unei psihotraume. Examenul psihologic a arătat, pe lângă elementele psihopatologice menționate, un

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deficit cognitiv ușor (MMSE=23); examenul CT cranian a decelat o atrofie corticală, iar dozarea TSH a indicat hipotiroidism. Diagnosticul pozitiv a fost unul provizoriu; Episod depresiv major sever, cu elemente psihotice. I.O. Demență ușoară. Diagnosticul diferențial a avut în vedere trei tipuri de entități psihopatologice și anume: 1) tulburare depresivă; 2) tulburare cognitivă; 3) tulburare psihotică, sau o combinație între acestea.S-a ales această formulare pentru a putea urmări evoluția simptomatologiei în dinamică. Se va reevalua lunar starea psihică a pacientei pentru a se vedea gradul ameliorării simptomatologiei în urma tratamentului psihiatric și endocrinologic. În felul acesta se urmărește ca diagnosticul de certitudine să beneficieze de proba terapeutică. Dacă simptomele cognitive se vor ameliora sub tratamentul administrat - antidepresiv, antipsihotic și de substituție hormonală atunci avem de a face cu o pseudodemență depresivă și se va aplica tratamentul aferent.Cuvinte cheie: pseudodemență depresivă, deficit cognitiv, hipotiroidism.

PSEUDODEMENTIA - A VARIANT FOR DEPRESSION (CASE REPORT)Depressive pseudodementia is a psychopathological condition occurring in elderly individuals. It consists of marked symptoms of dementia caused in fact by depression.Ms V.J., a 60-year-old woman, with known past psychiatric history, presented with the following symptoms: depressed mood, anxiety, vague paranoid thoughts, concentration and memory problems. The symptoms started about two years ago, triggered by a psychological trauma. Apart from aforementioned psychopathological elements, psychological evaluation revealed a mild cognitive deficit (MMSE score = 23 points). Brain CT exam revealed cerebral cortical atrophy. TSH blood level confirmed the hypothyroidism. The temporary diagnosis was "Severe depressive episode with psychotic features. Mild dementia (under observation)". The differential diagnosis considered three psychopathological entities: 1) depressive disorder; 2) cognitive disorder; 3) psychotic disorder, or a combination of these.This wording has been chosen to enable symptoms dynamics follow-up. To evaluate the outcome of psychiatric and endocrine therapy, the patient's mental state will be periodically reassessed, on a monthly basis. This way, the final diagnosis will take into account the therapeutic test. If cognitive symptoms will improve with antidepressant, antipsychotic and hormonal therapy, then this is a case of depressive pseudodementia and appropriate therapy will be offered.Keywords: depressive pseudodementia, cognitive deficit, hypothyroidism.

C O N C E P T D E S P R E S T I G M AT I Z A R E A PACIENȚILOR CU EPILEPSIE Elena Bounegru, Ghenadie Cărăușu USMF „Nicolae Testemiţanu”, Chişinău, Republica Moldova

Aproximativ 1% din populația globală suferă de epilepsie, iar 80% dintre cazuri se înregistrează în țările în curs de

dezvoltare. Maladia poate avea efecte diverse asupra bunăstării sociale și psihologice a bolnavilor. Prin urmare, dezonorarea din partea comunității a pacienților cu epilepsie este acel impact ce formează stigmatizarea. Stigmatul epilepsiei poate, de asemenea, afecta și familiile celor bolnavi. Acest fenomen include stigmatizarea publică, autostigmatizarea și stigmatizarea familiară. Studiile anterioare au demonstrat că stigmatizarea bolnavilor cu epilepsie este mult mai mare comparativ cu alte maladii psihiatrice. Scopul acestei lucrări a constat în estimarea nivelului stigmei la pacienții epileptici, evaluarea stării afective a acestora. Pentru realizarea scopului au fost luați în studiu 50 de pacienți cu epilepsie, dar și un grup de control, constituit din 25 de bolnavi cu tulburări mentale organice și 25 de subiecți – membri ai familiei. Metodele utilizate sunt următoarele: chestionarul pentru evaluarea factorilor stigmatizării dominanți în epilepsie, scala Hamilton, chestionarul Beck, testul MMSE, scala Rosenberg. Datele au demonstrat că epilepsia se impune ca o problemă majoră de sănătate publică prin consecințele sale medicale, sociale, culturale și economice. Pentru aceste persoane efectele negative ale stigmatizării includ: refuzul de a căuta tratament, respingerea subiecților de către familie și prieteni, probleme în găsirea unui serviciu, etc. Cuvinte cheie: epilepsie, stigmatizare, autostigmatizare, stigmatizare publică, stigmatizare familiară.

CONCEPT ABOUT THE STIGMATIZATION OF PATIENTS WITH EPILEPSYAbout 1% of the global population suffers from epilepsy and 80% of cases are recorded in developing countries. The disease can have various effects on social and psychological well-being of patients. Therefore, dishonoring the community of patients with epilepsy represents an impact that forms the stigmatization of society. The stigmatization of epilepsy may also affect the families of these patients. This phenomenon includes public stigma, and self-stigmatization in family stigma. Previous studies have shown that the number of patients with epilepsy that are stigmatized is much higher compared to other psychiatric diseases. The purpose of this study was to estimate the level of stigmatization in epileptic patients, assessing their emotional state. In order to achieve this, we included 50 patients with epilepsy in the study and a control group consisting of 25 patients with organic mental disorders and 25 subjects - family members. Used methods: questionnaire to assess stigma dominant factors in epilepsy, Hamilton scale, Beck questionnaire, MMSE test, Rosenberg scale. The data showed that epilepsy is imposed as a major public health problem through its medical, social, cultural and economic consequences. For these people the negative effects of stigma include: refusal to find out an efficient treatment, subjects are rejected by family and friends, problems in finding a job, etc.Keywords: epilepsy, stigmatization, self-stigmatization, public stigma, family stigma.

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INTERNETUL ÎN VIAȚA STUDENȚILOR MEDICINIȘTI Lavinia Duică, Ionuţ NistorUniversitatea “Lucian Blaga” Sibiu, Romania

Introducere. Implementarea internetului în domeniul medical îşi are utilitatea în multiple sectoare: formare profesională, studii statistice, difuzarea informaţiei, calculul finanţării, cercetarea ştiinţifică, teleconferinte, etc. Scop. În această lucrare ne propunem să facem o radiografiere a mijloacelor de informare profesională utilizate de studenţii medicinisti, incluzand internetul precum şi prezenţa dependenţei de internet la aceştia.Metodă. Studiul a fost efectuat pe un eşantion de 1276 de studenţi din toate facultăţile de medicină din tară. Participanţii au completat un chestionar cu date de identificare şi întrebări legate de dezvoltare profesională si un al doilea chestionar despre dependenţa de internet (Testul adicţiei la internet, Young K.S).Rezultate şi discutii. Lotul cuprinde 18,3% studenţi de gen masculin, iar restul de 81,7% au fost de gen feminin. Din numărul total de 1276 de participanţi la studiu, 8,2% prezintă dependenţă moderată şi 0,4% dependenţă severă, restul fiind fără dependenţă sau cu dependenţă usoară. Repartiţia pe centre a arătat că, în ceea ce priveşte dependenţa moderată, cei mai mulţi provin din Iaşi (22.1%), urmaţi fiind de cei din Timişoara (21.2%), Bucureşti (12.5%), Craiova şi Constanţa (9.6%). În ceea ce priveşte pregătirea profesională prin utilizarea internetului, aceasta cuprinde şi informaţii legate de dezvoltarea profesională. Cercetarea mijloacelor de pregătire profesională a arătat că: frecventarea cursurilor îi ajută mult pe studenţi în acumularea cunostinţelor (41,9%), frecventarea bibliotecii nu prezintă interes pentru acumularea de cunoştinţe (58,4%); navigarea pe site-uri medicale este benefică studiului pentru un examen (45,4%).Concluzii. Din totalul participanţilor la studiu, sub 10% dintre studenţi prezintă un grad mai crescut al dependenţei de internet, dintre care cei mai multi provin din Iaşi şi Timişoara; internetul reprezintă un mijloc important al pregătirii profesionale, de asemenea este importantă şi participarea la cursuri, în timp ce frecventarea bibliotecilor contribuie în mai mică măsură la acumularea cunostinţelor.Cuvinte cheie: internet, studenţi medicinisti, dependenţă.

INTERNET IN THE LIFE OF MEDICAL STUDENTS Introduction. Internet implementation in medical field covers multiple health-related activities: professional training, statistical studies, knowledge transfer, finance accounting, scientific research, teleconferences etc.Objective. This study aims to determine the pattern of professional training practices (including the internet) in undergraduate medical students and the prevalence of internet addiction in this subset of population.Methods. The study included 1276 medical students from all Romanian universities. Demographic data and details about professional training practices were collected. Young's Internet Addiction Test questionnaire was administered.Results and discussion. A total of 18.3% of the study

subjects were males and 81.7% females. 8.2% presented moderate addiction and 0.4% severe addiction, the rest were without / mild addiction. Among the moderate addiction group, most subjects were originating from Iasi (22.1%), followed by those from Timisoara (21.2%), Bucharest (12.5), Craiova and Constanta (9.6%). Medical students' professional training practices included the internet use; attending courses has a significant role in developing medical knowledge (41.9%); library attendance does not present interest (58.4%); navigating medical internet sites is beneficial for exam preparation (45.4%).Conclusion. Less than 10% of medical students presented a higher severity grading of internet addiction, most of them originating from Iasi and Timisoara. The internet plays a significant role in professional training along with attending courses, while library attendance has a less significant contribution in medical training.Keywords: internet, medical students, dependence.

UNELE CARACTERISTICI CLINICE ALE BOLNAVILOR CU TULBURĂRI DISOCIATIVE

1,3 2 1Irina Hâncu , Ion Moldovanu , Ghenadie Cărăuşu1Catedra de psihiatrie, narcologie şi psihologie medicală, USMF „Nicolae Testemiţanu”, Chişinău, Republica Moldova2Catedra de neurologie, USMF „Nicolae Testemiţanu” , Chişinău, Republica Moldova3Centrul de Sănătate Mentală Buiucani, Chişinău, Republica Moldova

Incidența subiecților cu tulburări disociative (de conversie) este de 2-5 bolnavi la 100.000 pe an. Prevalența pe durata vieţii a acestor tulburări în populația generală se situează între 3 şi 6 la 1000 la femei şi mult mai puțin la bărbați. Tulburările de conversie trebuie diferențiate de multitudinea de afecţiuni somatice, care produc dereglări similare, cea mai mare dificultate apare cu bolile organice ale SNC. Astfel că tulburarea de conversie, prin vulnerabilitatea ei multifactorială, impune o abordare pluridimensională şi sistematizată a acestei probleme. Scopul cercetării a constat în evaluarea manifestărilor clinice specifice, evidenţierea impactului diverşilor factori în dezvoltarea lor şi elaborarea conduitei eficace de tratament. În studiu au fost incluse 7 paciente, cu vârsta medie de 38,71±0,32 ani și o durată medie de spitalizare de 19,02±0,44 zile. Lucrarea a demonstrat că caracterul mişcărilor în tulburările de conversie motorie a fost lent, inconsecvent, care necesita un efort din partea pacientelor, dar creştea odată cu atragerea atenţiei. Exista şi o disociere între performanţă la interviu şi performanţa spontană a mişcărilor atunci când bolnavele nu erau examinate. Tremorul era variabil ca frecvenţă, neregulat, cu tendinţă să dispară la distragere. Cauzele cele mai frecvente ale declanşării maladiei au fost situaţiile conflictuale în propria familie: neîmpărtăşirea afectului, suport emoţional redus, lipsa relaţiei de încredere, sentiment de singurătate, ratare a vieţii personale. Măsurile de recuperare în staţionar a pacienţilor au fost complexe, și au inclus intervenţii farmaco - şi psihoterapeutice. Cuvinte cheie: tulburări disociative, tremor psihogen, intervenţii terapeutice.

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SOME CLINICAL FEATURES OF PATIENTS WITH DISSOCIATIVE DISORDERS

The incidence of subjects with dissociative disorders (conversion) is 2-5 per 100,000 patients per year. Lifetime prevalence of these disorders in the general population is between 3 and 6 from 1000 women and to less than men. Conversion disorder must be distinguished from the multitude of somatic disorders that cause similar disorders, the greatest difficulty arises with organic diseases of the CNS. Conversion disorder through its multifactorial vulnerability requires a systematic approach to this problem. The purpose of the study was to assess specific clinical manifestations, highlighting the impact of various factors in their development and elaboration conduct effective treatment. The study included seven patients with a mean age of 38.71 ± 0.32 years and a mean duration of hospitalization of 19.02 ± 0.44 days. The work has shown that the character movements in motor conversion disorder has been slow, inconsistent, requiring an effort from patients, but increased with attracting attention. There was a dissociation between performance at interview and performance of spontaneous movements when the patients were examined. The tremor was variable in frequency, irregular, prone to distractions disappear. Common causes of disease onset were conflicting situations in his own family: not sharing affect, reduced emotional support, lack of trust, sense of loneliness, failure of personal life. Recovery measures inpatient patients were complex and included pharmaco- and psychotherapy interventions.Keywords: dissociative disorders, psychogenic tremor, therapeutic interventions.

C A R A C T E R I S T I C I C L I N I C O -PSIHOPATOLOGICE ALE FAMILIILOR PACIENȚILOR CU ALCOOLDEPENDENȚĂ

1,3 2 1Maria Rotaru , Larisa Spinei , Ghenadie Cărăuşu1Catedra de psihiatrie, narcologie şi psihologie medicală IP USMF „Nicolae Testemiţanu”, Chișinău, Republica Moldova2Şcoala de Management în Sănătate Publică IP USMF „Nicolae Testemiţanu”, Chișinău, Republica Moldova3IMSP Dispensarul Republican de Narcologie, Chișinău, Republica Moldova

Scopul lucrării a constat în studierea caracteristicilor c l i n i c o - p s i h o p a t o l o g i c e a l e p e r s o a n e l o r alcooldependente, evaluarea gradului de codependenţă, formelor de comportament codependent a aparținătorilor. Lucrarea a demonstrat că persoanele cu alcoolism cronic manifestă sentimente de singurătate și de ratare a vieţii personale, iar factorii, care provoacă atracția fată de alcool, în răstimpul dintre excese, sunt stările mixte de anxietate, nelinişte, irascibilitate şi insomnie. Studiul denotă că gradul de codependenţă a membrilor familiei este puternic manifest. Rezultatele noastre atestă că marea majoritate a persoanelor codependente au fost expuse unor factori nefavorabili în familie, iar atitudinea rudelor față de consumul de alcool a fost dezaprobatoare în peste 50 % din cazuri. Aparținătorii se deosebeau prin responsabilitate excesivă pentru membrii familiei, griji pentru lucrurile pe care nu le pot influența, siguranța că fericirea lor depinde de ceilalți, lipsă de echilibru între

dependență și independență. Datele denotă următoarele forme de comportament codependent în familie: controlarea comportamentului și vieții alcoolicului prin evitarea participării la diferite evenimente și situații în care se știe că se consumă băuturi, preluarea responsabilităților în locul persoanei dependente, scuzarea comportamentului persoanei dependente în față celor apropiați. Cuvinte cheie: alcooldependență, comportament codependent, microclimat familial, anxietate.

CLINICAL-PSYCHOPATHOLOGY FEATURES OF FAMILIES OF PATIENTS WITH CHRONIC ALCOHOLISMThe aim of the work was to study the clinical-psychopathological characteristics of persons with chronic alcoholism, evaluating the codependency, forms of codependent behavior of carers. The work has shown that people with chronic alcoholism exhibit feelings of loneliness and failure of personal life and the factors that cause attraction to alcohol, in the period between excesses are mixed states of anxiety, restlessness, irritability and insomnia. The study shows that the degree of codependency family members is strongly manifest. Our results attest to the vast majority of codependent people were exposed to unfavorable factors in the family, relatives and attitude towards alcohol consumption was disapproving in 50% of cases. Carers differed by excessive responsibility for family members, worried about the things they cannot influence the assurance that their happiness depends on others, lack of balance between dependence and independence. The data reveals the following forms of behavior codependent family: controlling behavior and life by avoiding alcoholic various events and situations that are known to consume drinks, taking over responsibilities instead dependent person, condoning behavior dependent person in front of close.Keywords: chronic alcoholism, codependent behavior, family microclimate, anxiety.

GRADUL DE STRES ȘI CONSUMUL DE ALCOOL ÎN BOLILE HEPATICE CRONICE DE ETIOLOGIE VIRALĂ

1 2 1Victor Gheorman , Anca Livia Chiriță , Silvia Ristea , Ion 2 2 2Rogoveanu , Felicia Militaru , Ion Udriștoiu

1Școala Doctorală, Universitatea de Medicină și Farmacie din Craiova, Romania2Universitatea de Medicină și Farmacie din Craiova, Romania

Introducere. Alcoolul reprezintă în zilele noastre substanța de abuz cel mai des utilizată la nivel mondial de cele mai diverse categorii de consumatori. Cu toate că nu este catalogat ca medicament, foarte multe persoane utilizează alcoolul ca un „antidot” la adresa problemelor personale, sociale sau profesionale cu care se confruntă zilnic. Fiind relativ ieftin și de obicei ușor de achiziționat, alcoolul este folosit adesea pentru reducerea stresului, a anxietății sau a simptomelor depresive. Cu toate acestea, subliniem faptul că alcoolul nu are o acțiune farmacologică de tip antidepresiv, ba mai mult, simptomatologia depresivă este accentuată de alcool în repetate rânduri. Așadar, din substanță anxiolitică, alcoolul devine anxiogen, agravând dispoziția, labilitatea afectivă, anhedonia, retragerea


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socială, gradul de stres și tensiunea intrapsihică.Metodă. Cercetarea noastră s-a desfășurat pe un lot de 124 de bolnavi diagnosticați cu boală hepatică cu evoluție cronică de etiologie virală internați în Clinica de Gastroenterologie a Spitalului Clinic Județean de Urgență Craiova. Evaluarea gradului de stres al participanților la studiu s-a realizat printr-o metodă subiectivă (pacienții au fost rugați să aleagă gradul de stres: redus, mediu sau ridicat), cât și printr-o metodă pe care am dorit-o mai obiectivă (participanții fiind invitați să completeze chestionarul CERQ cu 36 întrebări legate de diverse probleme și situații din viața personală; la fiecare item ei erau rugați să indice un scor între 1 și 5.) Totodată, pacienții au fost chestionați privind consumul de băuturi alcoolice prin testul AUDIT (Testul de identificare a afecțiunilor cauzate de consumul de alcool), fiind rugați să specifice frecvența și cantitatea consumului, sentimentele de vinovăție, atitudinea anturajului.Rezultate. Dependența de alcool moderată și severă evaluată prin testul AUDIT s-a corelat cu valori ridicate (cel puțin 3) ale itemilor legați de sentimentele de deznădejde (17, 20, 35), culpabilitate (19). În ansamblul lotului, femeile au manifestat o atitudine mai optimistă față de evenimentele negative, notând scoruri mari (4-5) la itemii legați de speranță și planuri de viitor (4, 6, 13, 22, 24). La pacienții de sex masculin am notat totodată tendința de a învinui alte persoane pentru situația stresantă (scoruri înalte la itemii 9, 18, 36).Concluzii. Studiul nostru a arătat corelații sugestive între consumul de alcool și diferite nivele de stres. Cu cât dependența de alcool este mai accentuată, scade capacitatea de a face față evenimentelor negative și cresc în intensitate sentimentele de deznădejde și pesimism, în directă corelație cu severitatea afecțiunii somatice.Cuvinte cheie: alcool, stres, boală hepatică cronică.

THE DEGREE OF STRESS AND ALCOHOL USE IN CHRONIC LIVER DISEASES OF VIRAL ETIOLOGYIntroduction. Alcohol is nowadays the substance of abuse most commonly used worldwide for various categories of consumers. Although not classified as a drug, many people use alcohol as an „antidote” to address personal social or professional issues faced daily. Relatively cheap and easy to purchase, alcohol is often used to reduce stress, anxiety or depressive symptoms. However, we emphasize that alcohol has not a pharmacological action of antidepressant type; moreover, the depressive symptoms following alcohol abuse are often increased. Thus, the effects of alcohol use are the increase of anxiety, worsening mood, emotional lability, anhedonia, social withdrawal, degree of stress and intrapsychic tension.Method. Our research was conducted on a sample of 124 patients diagnosed with chronic liver disease of viral etiology admitted in the Gastroenterology Clinic of the Emergency County Hospital Craiova. Assessment of stress in study participants was quantified by a subjective method (patients were asked to choose the degree of stress: low, medium or high) and by an objective scale (participants were invited to complete the CERQ questionnaire with 36 questions related to various issues and situations in personal life; at every item they were asked to indicate a score between 1 and 5). Also, the patients were questioned about alcohol consumption by

AUDIT test (test identification disorders caused by alcohol), were asked to specify the frequency and amount of consumption, feelings of guilt, attitude entourage.Results. Moderate and severe alcohol dependence assessed by AUDIT test was correlated with elevated scores (at least 3) on the items related to feelings of hopelessness (17, 20, 35) and guilt (19). In our sample, women showed a more positive attitude towards negative events, noting higher scores (4-5) on items related to hope and future plans (4, 6, 13, 22, 24). We also noted the tendency to blame others for stressful situation in male patients (higher scores on items 9, 18, 36).Conclusion. Our study highlighted suggestive correlations between alcohol use and different levels of stress. Patients with moderate/severe alcohol dependence are less able to cope with negative events and show intense feelings of despair and pessimism, directly correlated with the severity of the somatic disease.Keywords: alcohol, stress, chronic liver disease.

INFLUENȚA MEDIULUI DE PROVENIENȚĂ ASUPRA GRADULUI DE STRES LA BOLNAVII CU AFECȚIUNI CRONICE HEPATICE VIRALE

1 2 2Silvia Ristea , Anca Livia Chiriță , Ion Udriștoiu , Mihai 2Cristian Pîrlog ,

2 1Felicia Militaru , Victor Gheorman1Școala Doctorală, Universitatea de Medicină și Farmacie din Craiova, Romania2Universitatea de Medicină și Farmacie din Craiova, Romania

Introducere. Studiile din literatura de specialitate au demonstrat cifre diferite între apariția și evoluția bolilor hepatice cronice și mediul de proveniență. Corelațiile dintre afecțiunile hepatice cronice de etiologie virală și gradul de stres sunt evidente, însă cercetarea de față își propune stabilirea gradului de influență pe care îl exercită asupra gradului de stres mediul de proveniență al pacienților diagnosticați cu boală hepatică virală.Metodă. Studiul s-a desfășurat în perioada 01.01.2015-30.06.2016 și a cuprins un lot de 124 de pacienți cu hepatită cronica de etiologie virala internați în Clinica de Gastroenterologie a Spitalului Clinic Județean de Urgență Craiova. Participanții la studiu au fost rugați să completeze chestionarul SACS de abordare strategică a copingului, cu 52 itemi abordând diverse probleme de relaționare și personale stresante, oferind fiecărei întrebări un scor de la 1 la 5. La finalul testului s-a realizat un scorul total obținut din cumularea răspunsurilor obținute. Apoi am studiat corelațiile între capacitatea de rezistență la stres a pacienților, așa cum reiese din chestionar și mediul de proveniență.Rezultate. Pacienții din mediul rural au obținut scoruri înalte la itemii legați de relațiile sociale (2, 13, 23, 51), în timp ce pacienții din urban au afirmat deficite de relaționare cu anturajul. Aceștia din urmă, au obținut însă scoruri ridicate (mai ales bărbații) la itemii legați de agresivitate și impulsivitate (8, 11, 16, 19, 42). Totodată, cei din mediul rural au afirmat o abordare strategică, graduală a situației stresante (scoruri de 4 și 5 la itemii 12, 24, 40), în timp ce pacienții din urban au manifestat egoism accentuat (scoruri înalte la itemii 4, 16, 34, 44).Concluzii. În urma cercetării noastre, am putut stabili asocieri interesante, unele chiar surprinzătoare între

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mediul de proveniență și gradul de stres la pacienții cu boală hepatică de etiologie virală. Astfel, pacienții din mediul rural au manifestat mai mult altruism și o capacitate ridicată de a face față situațiilor stresante, indiferent de sex.Cuvinte cheie: stres, mediu de proveniență, hepatită virală.

THE INFLUENCE OF RESIDENCE ON THE DEGREE OF STRESS IN PATIENTS WITH CHRONIC VIRAL LIVER DISEASESIntroduction. Various studies have highlighted different correlations between the onset and course of chronic liver diseases and residence of the subjects. Correlations between chronic liver diseases of viral etiology and degree of stress are obvious, but research aims to determine the influence that residence may exercise on the degree of stress in patients diagnosed with viral liver diseases.Method. The present study was performed between 01.01.2015 and 30.06.2016, including a sample of 124 patients with chronic hepatitis of viral etiology admitted in the Gastroenterology Clinic of the Emergency County Hospital Craiova. The participants were asked to complete the SACS questionnaire of strategic approach to coping with 52 different items addressing relationship issues and personal stress, offering each question a score from 1 to 5. Finally, we obtained the total score by aggregating the answers. The capacity of coping of study participants was then correlated to their residence.Results. Patients from rural areas have achieved higher scores on the items related to social networking (2, 13, 23, 51), while patients in urban declared poor relationship with entourage. The latter have also achieved high scores (especially male) to the items related to aggressiveness and impulsivity (8, 11, 16, 19, 42). However, the rural claimed a strategic and gradually approach to stressful situations (scores of 4 and 5 on items 12, 24, 40), while patients in urban manifested pronounced selfishness (high scores on items 4, 16, 34, 44).Conclusions. Following our research, we could fix interesting, some surprising combinations between the area of origin and the degree of stress in patients with liver disease of viral etiology. Thus, patients from rural areas, regardless of gender, showed more altruism and a higher capacity to cope with stressful situations.Keywords: stress, area of origin, viral hepatitis.

MODIFICĂRILE VOLUMULUI HIPOCAMPAL CONSECUTIVE TERAPIILOR COGNITIV-COMPORTAMENTALE ÎN DEPRESIE

1 2 2Silvia Ristea , Felicia Militaru , Ileana Marinescu1Școala Doctorală, Universitatea de Medicină și Farmacie din Craiova, Romania2Universitatea de Medicină și Farmacie din Craiova, Romania

Tulburarea depresivă prin frecvenţa ridicată se constituie într-o veritabilă problemă publică. Mecanismele biologice susţin hiperactivitatea axei hipofizo-cortico-suprarenaliene cu hipercortizolemie endogenă, a cărei influenţă disprotectivă la nivelul hipocampului se concretizează prin instalarea atrofiei hipocampice. Studiile de neuroimagistică confirmă incidenţa semnificativ înaltă a atrofiei hipocampice în tulburarea

depresivă majoră.Hipocampul este o structură anatomică ce include multiple circuite cognitive, iar atrofia hipocampică este direct proporţională cu instalarea disfuncţiei cognitive. Utilizarea medicaţiei antidepresive ameliorează conflictul intersinaptic de neurotransmisie, diminuând hiperactivitatea cortizolică endogenă.Psihoterapiile de inspiraţie cognitivă, asociate medicaţiei antidepresive, conduc la un antrenament cognitiv ce poate stimula neurogeneza şi ameliora funcţionalitatea hipocampului, cu îmbunătăţirea pe termen mediu şi lung atât a depresiei, cât şi a funcţiilor cognitive.Cuvinte cheie: depresie, psihoterapie cognitiv-comportamentală, hipercortizolemie, disfuncţie cognitivă.

THE CHANGES OF HIPPOCAMPAL VOLUME SECONDARY TO COGNITIVE-BEHAVIORAL THERAPY IN DEPRESSIONDepressive disorder is a true public challenge due to the high prevalence and social implications. The biological mechanisms support the hyperactivity of the HPA axis with secondary hypercortisolemia and progressive hippocampal atrophy due to the dysprotective effects. The imaging studies have confirmed the significant incidence of hippocampal atrophy in major depressive disorder.Hippocampus is an anatomical structure that includes multiple cognitive circuits and the atrophy at this level is proportional with the degree of cognitive dysfunction. The use of antidepressant medication improves the inter-synaptic conflict of neurotransmission by reducing the endogenous cortisolic hyperactivity.Cognitive psychotherapies associated to the antidepressant therapy stimulate the cognitive training that may trigger neurogenesis and ameliorate the functionality of hippocampus, thus improving on medium- and long-term both the depressive symptoms and the cognitive functions.Keywords: depression, cognitive-behavioral therapy, hipercortisolemia, cognitive dysfunction.

POSTER

PARTICULARITĂȚI ALE ADMINISTRĂRII ANTIPSIHOTICELOR ÎN TIMPUL SARCINIIVasile Chiriţă, Ilinca Untu, Dania Andreea Radu, Roxana ChiriţăUniversitatea de Medicină și Farmacie „Gr. T. Popa”, Iaşi, Romania

Background teoretic. Utilizarea medicaţiei psihotrope şi mai ales a antipsihoticelor în timpul sarcinii, constituie o reală provocare terapeutică, dată fiind antiteza dintre nevoia de a controla simptomele psihotice cu potenţială periculozitate pentru mamă cât şi pentru făt şi efectele adverse ale acestei medicaţii asupra dezvoltării in utero a fătului şi implicit, asupra stării sale postnatale. Antipsihoticele sunt medicaţia de elecţie pentru tratarea schizofreniei şi a tulburărilor de spectru, având o eficacitate probată, iar utilizarea lor fiind chiar imperioasă şi în alte tulburări psihiatrice majore care asociază simptome psihotice. Obiective. Lucrarea de faţă îşi propune realizarea unei

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sinteze a literaturii de specialitate cu privire la particularităţile administrării medicaţiei antipshotice pe durata sarcinii, ţinând cont de argumentele în favoarea şi în defavoarea acesteia şi raportându-ne la contrastul dintre impactul sever pe care administrarea antipsihoticelor îl poate avea asupra fătului, mergând până la defecte de tub neural şi nevoia de a proteja mama şi indiect, fătul, de consecinţele severe pe care le pot avea simtomele psihotice. Materiale și metode. Lucrarea de faţă este alcătuită sub forma unei sinteze a literaturii actuale de specialitate, constituid o analiză a unor cercetări publicate între 2012-2015, referitoare la riscurile şi beneficiile administrării antipsihoticelor în sarcină. Rezultate si discuţii. Efectele antipsihoticelor asupra dezvoltării tubului neural sunt binecunoscute, având rasunet important în ceea ce priveşte structurile cerebrale şi coloana vertebrală, risc major pentru saptămânile 2-9 de sarcină. Studiile arată în unanimitate că prin prezenţa receptorilor dopainergici D1,D2, D4 în placenta umană, antipsihoticele ce actionează prin excelenţă pe aceşti receptori, produc o scădere uneori dramatică a eliberarii hPL, hormon similar hormonului de creştere . Alte antipsihotice pot induce agranulocitoză mamei dar şi fătului, fiind ameninţătoare de viaţă, în ciuda potenţei lor în privinţa controlului simptomelor psihotice. Alte date ştiinţifice, uneori contradictorii, pledează pentru riscul de geutate mică la naştere consecutivă tratării mamei cu antipsihotice pe durata sarcinii. Altele indică tocmai riscul de macrosomie. Totodată, dincolo de efectele nocive asupra fătului, antipsihoticele atipice asociază un risc crescut de diabet gestaţional. Concluzii. Cu toate acestea, ghidurile terapeutice în vigoare subliniază necesitatea continuării terapei antipsihotice în contextul în care simptomele psihotice sunt o urgenţă psihiatrică majoră şi pot deveni în consecinţă şi una obstetricală.Cuvinte cheie: antipsihotice atipice în sarcină, defecte de tub neural, sarcină, antipsihotice atipice, managementul psihozelor pe durata sarcinii

PA R T I C U L A R I T I E S A D M I N I S T E R I N G ANTIPSYCHOTICS DURING PREGNANCYBackground. The use of psychotropic medication and mostly of antipsychotics during pregnancy is a real therapeutic challenge, considering the antithesis between the need to control psychotic symptoms and the potential danger for the mother and the fetus, as well as the adverse effects of this medication upon the in utero development of the fetus and upon its postnatal status, implicitly. Antipsychotics are first choice drugs for treating schizophrenia and other disorders of the same spectrum; its effectiveness has been proven and its necessity has been deemed imperious in other major psychiatric disorders, too, if they associate psychotic symptoms. Objectives. This paper proposes a review of the literature on the particularities of administering antipsychotic medication during pregnancy, taking into account the pro and con arguments in relation to the contrast between the severe impact of antipsychotics on the fetus (as serious as neural tube defects) and the need to protect the mother and the fetus, implicitly, from the severe consequences of psychotic symptoms. Materials and methods. This paper represents a review of

the current literature, because it analyzes studies published in 2012-2015, on the risks and benefits of administering antipsychotic medication during pregnancy. Results and discussions. The effects of antipsychotics upon the development of the neural tube are well known: they alter significantly the brain structures and the spine, which represents a major risk for the second through the ninth week of pregnancy. Studies show unanimously that – through the presence of dopamine receptors D1, D2 and D4 in the human placenta – antipsychotics act par excellence on these receptors and sometimes they produce a dramatic drop in the release of hPL, a hormone similar to growth hormone. Other antipsychotics can induce agranulocytosis for both mother and fetus; this condition is life threatening, despite the medication's efficiency in the control of psychotic symptoms. Other scientific data – contradictory at times – plead for the risk of low birth weight consecutive to administering antipsychotics to the mother during pregnancy. Other studies suggest precisely the risk of macrosomia. At the same time, beyond the harmful effects on the fetus, atypical antipsychotics sometimes make the mother more prone to gestational diabetes. Conclusions. Nonetheless, the therapeutic guidelines in effect underscore the need to continue administering antipsychotics considering that psychotic symptoms are a major psychiatric emergency, which means they may also become an obstetric emergency.Keywords: atypical antipsychotics during pregnancy, neural tube defects, pregnancy, atypical antipsychotics, management of psychoses during pregnancy

INDICAŢII STANDARD ŞI OFF LABEL ALE PALIPERIDONEI – SINTEZĂ A LITERATURII DE SPECIALITATEIlinca Untu, Vasile Chiriţă, Dania Andreea Radu, Roxana ChiriţăUniversitatea de Medicină și Farmacie „Gr. T. Popa”, Iaşi, Romania

Background teoretic. Paliperidona este un antipsihotic de a doua generaţie, recent aprobat pentru tratamentul psihofarmacologic al schizofreniei şi al tulburării schizoafective. Acest antipsihotic atipic reprezintă un metabolit activ al risperidonei, antipsihotic de a doua generatie, cu utilizare raspandită în spectrul psihotic. Dat fiind faptul ca Paliperidona diferă printr-o singură grupare hidroxil de risperidonă, există o controversă privind realele diferenţe în ceea ce priveşte acţiunea terapeutică, cât şi indicaţiile celor doua. Obiective. Lucrarea de faţă îşi propune realizarea unei sinteze a literaturii de specialitate vizând indicaţiile terapeutice aprobate cât şi cele off label ale Paliperidonei. Materiale şi metode. Sinteza literaturii de specialitate s-a realizat prin analiza si selectarea datelor esenţiale dintr-o serie de lucrări publicate în jurnale medicale de prestigiu internaţional, selectate din baza de date Pub Med, precum şi din ghiduri terapeutice prestigioase vizând tratamentul psihofarmacologic. Rezultate si discutii. Literatura de specialitate indica faptul ca Paliperidona are ca destinaţie de elecţie, tratamentul schizofreniei la adulţi, tratamentul schizofreniei la copii şi adolescenţi cu vârsta între 12-17

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ani şi tratamentul tulburării schizoafective fie ca monoterapie, fie în asociere cu timostabilizatoare sau cu antidepresive. Deocamdată însă, nu a fost dovedita eficienţa sa în tratarea schizofreniei la copii cu vârsta sub 12 ani şi nici în tratarea tulburării schizoafective la pacienţi cu vârsta sub 18 ani. Literatura actuală de specialitate subliniază faptul că principalele indicaţii off label ale Paliperidonei vizează tocmai populaţia pediatrică sub 12 ani, având rezultate promiţătoare în abordul terapeutic psihofarmacologic al tulburarilor de deficit de atenţie, dar şi în tulburările pervazive ale dezvoltării, mai ales în controlul iritabilităţii. Concluzii. Paliperidona aduce cu sine potenţialul eficacităţii şi în alte afecţiuni psihiatrice majore care vizează şi populaţia pediatrică. Dincolo de asemănările structurale cu risperidona, paliperidona are o serie de particularităţi care deschid noi perspective în abordul terapeutic psihofarmacologic al tulburărilor psihiatrice.Cuvinte cheie: paliperidona, indicaţii terapeutice ale paliperidonei, indicaţii terapeutice off label ale paliperidonei.

STANDARD AND OFF LABEL INDICATIONS OF PALIPERIDONE – LITERATURE REVIEWTheoretical Background. Paliperidone is a second-generation antipsychotic, recently approved for the psychopharmacological treatment of schizophrenia and of schizoaffective disorder. This atypical antipsychotic represents an active metabolite of Risperidone, in its turn a second-generation antipsychotic largely used for psychotic disorders. Considering that Paliperidone is different from Risperidone by a single hydroxyl group, there is a real controversy surrounding the actual differences in terms of therapeutic action and indications of the two medications. Objectives. This paper proposes a literature review concerning the approved and off label therapeutic indications of Paliperidone. Materials and methods. The literature review of the therapeutic indications of Paliperidone was conducted by analyzing and selecting essential data within a series of works published in prestigious international medical journals, from the Pub Med database and from prestigious therapeutic guidelines on psychopharmacological treatment. Results and discussions. Scientific literature indicates that the first choice destination for Paliperidone – unanimously accepted and included within updated therapeutic guidelines – is the treatment of schizophrenia in adults, the treatment of schizophrenia in children and adolescents aged 12-17 and the treatment of schizoaffective disorder, as the only medication or in association with mood stabilizers or with antidepressants. However, its efficiency for treating schizophrenia in children under 12 and for treating schizoaffective disorder for persons under 18 has not been proven thus far. The current scientific literature underscores that the main off label indications of Paliperidone target precisely the pediatric population under 12, with promising results on the psychopharmacological therapeutic approach to attention deficit disorders, as well as in pervasive developmental disorders, mostly in irritability control. Conclusions. Paliperidone is a new molecule approved for the psychopharmacological treatment of schizophrenic

disorders, but with therapeutic potential in other major mental disorders, in the case of pediatric population, too. Beyond its structural similarities to Risperidone, Paliperidone has a series of particularities that open new perspectives in psychopharmacological therapeutic approach to psychiatric disorders. Keywords: paliperidone, therapeutic indications of Paliperidone, off label therapeutic indications of Paliperidone.

NOI ABORDĂRI PENTRU EVALUAREA ȘI Î M B U N Ă T Ă Ț I R E A C A L I T Ă Ț I I V I E Ț I I PERSOANELOR CU PROBLEME DE SĂNĂTATE MINTALĂ

1 1 2 3Maria Ladea , Mihai Bran , Marcel Sarpe , Victor Briciu1Universitatea de Medicina si Farmacie „Carol Davila”, București, Romania2CMI Marcel Șarpe, Focșani, Vrancea, Romania3Universitatea Transilvania, Brașov, Romania

Introducere. Calitatea vieții poate fi definită prin starea de bunăstare a unei persoane și satisfacția față de circumstanțele de viață, precum și prin starea de sănătate a unei persoane și accesul la resurse și oportunități. Descoperirea și tratarea doar a simptomelor psihopatologice nu este suficienta și informații cu privire la funcționarea socială și calitatea vieții ar trebui să fie considerate ca fiind esențiale pentru evaluarea rezultatelor pe termen lung pentru pacienții cu probleme de sănătate mintală.Obiective. Dezvoltarea unei aplicații mobile ușor de utilizat pentru evaluarea calității vieții pacienților cu schizofrenie.Metodă. O echipă multidisciplinară a dezvoltat o aplicație mobilă pentru iOS numit LIFE. Aplicația evaluează calitatea vieții și satisfacția tratamentului administrat. Acesta folosește o forma adaptata in romana a Quality of Life Enjoyment and Satisfaction Questionnaire – forma scurtă și a Medication Satisfaction Questionnaire. Design-ul aplicației LIFE este prietenos și aplicația are 3 module: date demografice, istoricul medical și de tratament, evaluarea calității vieții și a satisfacției la medicație.Rezultate. Aplicația a fost lansată la începutul lunii octombrie 2015 și este gratuita pentru a se descărca din Apple Store. Acesta a fost gândită ca un instrument ușor de utilizat atât pentru pacienți cât și pentru specialiștii în sănătate mintală. Concluzii. Noi tehnologii, cum ar fi aplicațiile mobile s-au dovedit a fi utile în evaluarea și îmbunătățirea calității vieții pentru utilizatori și aspecte similare trebuie să fie măsurate atunci când sunt utilizate de către persoanele cu probleme de sănătate mintală.Cuvinte cheie: calitatea vieții, aplicație mobilă, schizofrenie.

NEW APPROACHES FOR EVALUATING AND ENHANCING THE QUALITY OF LIFE OF PEOPLE WITH MENTAL HEALTH PROBLEMSIntroduction. Quality of life could be defined as a person's sense of wellbeing and satisfaction with his/her life circumstances, as well as a person's health status and access to resources and opportunities. Capturing and treating psychopathological symptoms alone it is not sufficient and information on the social functioning and

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quality of life should be regarded as essential for evaluating long-term outcomes for patients with mental health problems. Objective. To develop an easy to use mobile application for assessing the quality of life of patients with schizophrenia. Methods. A multidisciplinary team developed a mobile application for iOS called LIFE. The application assesses the quality of life and the medication satisfaction. It uses adapted Romanian forms of the Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form and Medication Satisfaction Questionnaire. The LIFE application design is user friendly and has 3 modules: demographic, medical and treatment history, life quality and medication satisfaction assessment.Results. The application was launched at the beginning of October 2015 and it's free to download from Apple Store. It is intended to be an easy to use tool for both patients and mental health specialist. Conclusion. New technologies like mobile applications proved to be useful in assessing and enhancing quality of life for users and similar aspects should be measured when used by people with mental health problems. Keywords: quality of life, mobile application, schizophrenia.

TRANSSEXUALISMUL – METODOLOGIA SCHIMBĂRII JURIDICE A SEXULUI

1 2 1Gabriela Costea , Valentin Gheorghiu , Francesca Culea , 3Bogdan Mălinescu

1Institutul Național de Medicină Legală ”Mina Minovici”, București, Romania2Universitatea de Medicină și Farmacie ”Carol Davila” București, Romania3Laboratorul de Medicină Legală ”Ilfov”, Romania

Introducere. Înlocuirea anatomică a sexului reprezintă o problemă psihiatrică, medico-legală, juridică și etică. Între criteriile diagnosticării transsexualismului și respectarea drepturilor și libertăților persoanei există numeroase verigi care trebuie rezolvate.Scop. Cunoașterea aspectelor multiple ale problematicii pacienților transsexuali.Discuții. Se prezintă succint criteriile de diagnosticare a transsexualismului și pașii necesari în vederea schimbării anatomice și juridice a sexului în țări care au reglementări privind această temă.Sunt prezentate ”bunele practici” (privind această problemă) în România precum și metodologia de expertizare medico-legală psihiatrică; concluziile raportului sunt necesare justiției și declanșării procedurilor terapeutice. Se detaliază pașii de expertizare și necesitatea expertizelor ”pe etape”. Se discută diferențe și asemănări cu metodologia din alte țări. Lucrarea este ilustrată cu cazuistică.Concluzii. În cazurile de transsexualism, concluziile raportului de expertiză medico-legală psihiatrică și a decizia instanței pot fi de recomandare și aprobare sau de refuz. Eventualul refuz al autorităților privind acceptarea schimbării anatomice a sexului și schimbarea sexului juridic nu reprezintă o încălcare a drepturilor și libertăților persoanei. Eventuala recomandare a solicitării pacientului nu reprezintă o încălcare a eticii medicale. Cuvinte cheie: Transsexualism, schimbarea juridică a

sexului.

TRANSSEXUALISM – THE METHODOLOGY OF LEGAL CHANGE OF THE ANATOMICAL SEXIntroduction. Replacing anatomical sex is a psychiatric, medico-legal, ethical and legal problem. There are many links between diagnostic criteria of transsexualism and respect for human rights and freedoms that need to be resolved.Scope. Knowledge of multiple aspects of the transsexual patients' issues.Discussions. There is briefly described the diagnostic criteria of transsexualism and steps to change the legal and anatomical sex in the countries with regulations on the subject. The authors are shown the 'good practice' (on this issue) in Romania and the methodology of the forensic psychiatric expertise; conclusions of this report is required by law and driving therapeutic procedures. We detail the steps of forensic psychiatric expertise and the need of "phased" expertise. It discusses the differences and similarities of Romanian methodology with other countries. The paper is illustrated with casuistry. Conclusions. In cases of transsexualism, the conclusions of the forensic psychiatric report and court decision can be recommendation and approval or denial. The eventual refusal of the authorities' acceptance of anatomical sex change is not an infringement of personal rights and freedoms. The patient referral request is not in breach of medical ethics.Keywords: Transsexualism, legal change of anatomical sex.

RECUNOAȘTEREA EMOȚIILOR DE CĂTRE PACIENȚII CU TULBURĂRI AFECTIVE PERIODICE

1 1 1Ion Papavă , Virgil-Radu Enătescu , Cristina Bredicean , 2 3 2Iris Drut , Sorana Raluca Papavă , Ruxandra Bărboianu

1Universitatea de Medicină şi Farmacie „Victor Babeş” Timişoara, România2Clinica de Psihiatrie “Eduard Pamfil” Timișoara, România3Cabinet Medical „Dr. Novac”, Timișoara, România

Introducere. Tulburarea afectivă bipolară și tulburarea depresivă recurentă, reprezintă principalele tulburări afective periodice. Studii anterioare au arătat că subiecții cu astfel de tulburări prezintă o judecată defectuoasă în recunoașterea emoțiilor faciale.Scop. Compararea gradului de recunoaștere a emoțiilor de bază de către depresivi recurenți versus bipolari, în cadrul unui studiu transversal.Material și metodă. Au fost selectate două loturi, cu 30 de subiecți fiecare, unul cu subiecţi diagnosticaţi cu Tulburare depresivă recurentă, iar cel de-al doilea cu subiecţi cu diagnostic de Tulburare afectivă bipolară, diagnostice conform ICD 10 WHO. Toţi subiecţii au fost evaluaţi când se aflau în stare de remisiune cu Emotions Revelead Photo Set (cu 15 imagini). Testul a constat în 15 fotografii în alb şi negru , câte două dintre ele reprezentând cele 7 emoţii universale (furia, surpriza, dezgustul, tristeţea, aroganţa, fericirea şi frica) în timp ce o fotografie este neutră.Rezultate. Cea mai puţin recunoscută emoţie pentru ambele loturi a fost emoţia de aroganţă, urmată de cea de

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furie. În ceea ce priveşte cea mai recunoscută emoţie, aceasta a fost aceeaşi pentru ambele loturi şi anume, emoţia de fericire. Între cele două loturi, diferenţe semnificative în ceea ce priveşte recunoaşterea emoţiilor au existat doar pentru emoţia de dezgust (p= 0.001). Aceasta a fost semnificativ mai frecvent recunoscută de către bipolari faţă de monopolari, peste jumătate dintre depresivii recurenţi nefiind capabili să o identifice. Concluzii. Exista diferenţei semnificative între cele două loturi în recunoașterea emoţiei de dezgust poate constitui un ajutor important în diferenţierea celor două tipuri de patologii, atunci când evoluția bolii până în acel moment nu a clarificat această situaţie.Cuvinte cheie: emoții, tulburare bipolară, depresie recurentă.

RECOGNIZING EMOTIONS BY PATIENTS WITH PERIODICAL AFFECTIVE DISORDERSIntroduction. Bipolar disorder and major depressive disorder represent the main periodical affective disorders. Previous studies have shown that subjects with such disorders show an impaired judgment in recognizing facial emotions.Aim. To compare the degree of recognition of basic emotions by recurrent depressive versus bipolar, in a cross-sectional study.Methods. There were selected two groups with 30 subjects each; one with subjects diagnosed with major depressive disorder and the second with bipolar disorder, diagnosis according to ICD-10 WHO. All subjects were assessed when they were in a state of remission with Emotions Revealed Photo Set (15 images). The test consists of 15 photographs in black and white, two of them representing the seven universal emotions (anger, surprise, disgust, sadness, pride, happiness and fear) while a picture is neutral.Results. The least recognized emotion for both groups was the emotion of arrogance, followed by anger. Regarding the most recognized emotion, it was the same for both groups, namely, the emotion of happiness. Between the two groups, significant differences in the recognition of emotions existed only for the emotion of disgust (p = 0.001). This was significantly more frequently recognized by bipolar versus unipolar depressed; more than half of the recurrent depressed, were unable to identify disgust. Conclusions. There are significant differences between the two groups in recognizing the emotion of disgust, this can be an important aid in differentiating the two types of pathologies when the disease course, so far, failed to clarify this situation.Keywords: emotions, bipolar disorder, recurrent depression.

ALCOOLISM: PARTICULARITĂȚI ALE ABILITĂȚII DE IDENTIFICARE A EMOȚIILOR

1 1 1Cristina Bredicean , Ion Papava , Cătălina Giurgi-Oncu , 2 3 4Mădălina Cristanovici , Anca Popescu , Zsolt Popovici ,

5Claudia Homorogan1Universitatea de Medicină și Farmacie Timișoara, Romania2South London and Maudsley NHS Foundation Trust Mental Health Learning Disabilities, United Kingdom3Universitatea de Medicină și Farmacie Tg-Mureș, Romania

4Ambulator Psihiatrie Timișoara, Romania5Secția Psihiatrie, Spitalul Clinic Județean de Urgență Timișoara, Romania Consumul de alcool se întâlnește frecvent în psihiatrie având manifestări clinice variate de la intoxicație până la sevraj și psihoză. Studiile clinice actuale au evidențiat că capacitatea de identificare a emoțiilor este scăzută la persoanele care consuma alcool acest aspect având implicații în funcționarea socială . Scop. Evaluarea capacității de identificare a emoților la subiecți cu consum cronic de alcool.Metodă. Au fost analizați un lot de 37 subiecți ( 33 bărbați și 4 femei) care au fost internați în Clinica de psihiatrie Timișoara pentru un diagnostic legat de consumul de alcool (conform ICD 10). Subiecții au fost introduși in studiu pe baza unor criterii de includere/excludere . Parametrii analizați au fost: socio-demografici (vârsta, gen, mediul de proveniență, școlarizare, statut marital), evaluarea consumului de alcool (durata consumului) și capacitatea de identificare a emoțiilor (Testul de citire a minții din priviri). Datele evaluate au fost prelucrate statistic.Rezultate. Lotul a fost format din 89% bărbați deoarece adresabilitatea lor este mai ridicată în serviciul de urgență; majoritatea subiecților (89%) au capacitatea de identificare a emoțiilor scăzută; emoțiile cel mai greu de identificat au fost iubirea si teama, emoții oarecum diferite; de asemenea, valorile scăzute la testul de citire a minții din priviri se corelează direct cu durata mai lungă a consumului de alcool.Concluzii. Consumul cronic de alcool se corelează direct cu scăderea capacității de identificare a emoțiilor, emoțiile cel mai greu de identificat fiind iubirea si teama. Cuvinte cheie: alcoolism, emoții, teoria minții.

ALCOHOLISM: PARTICULARITIES OF EMOTION RECOGNIZING ABILITYIntroduction. Chronic alcohol consumption is frequently found in psychiatry, having various clinical manifestations from intoxication to withdrawal and psychosis. Current clinical trials reveal that the ability to identify emotions is reduced in people who consume alcohol, having implications in the social functioning. The aim of the study was to assess the ability of identifying emotions in subjects with chronic alcohol consumption.Methods. A sample of 37 subjects were analyzed in this study (33 males and 4 females), who were hospitalized in the Psychiatry Clinic of Timisoara for a diagnosis related to alcohol consumption (according to ICD-10). Subjects were introduced in the trial based on inclusion/exclusion criteria. The analyzed parameters were: socio-demographic (age, gender, background, education level, marital status), alcohol assessment (the consumption time) and the ability of identifying emotions (Reading the Mind in the Eyes Test). The obtained data were statistically evaluated.Results. The lot was 89% composed of men, because of their higher addressability to the emergency services; most subjects (89%) having a low ability to identify emotions; the hardest identified emotions were love and fear, somehow different emotions; also low scores at the “Reading the mind in the eyes test” were directly correlated with longer duration of alcohol consumption.

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Conclusions. Chronic alcohol consumption is directly correlated with a decreased ability to identify emotions, the most difficult being love and fear.Keywords: alcoholism, emotions, theory of mind.

PATOLOGIA DEPRESIVĂ ȘI ANXIOASĂ DUPĂ NAȘTERE. PARTICULARITĂȚI CLINICE

1 1Geanina Bulat , Claudia Homorogan , Cristina 2 2Bredicean , Monica Ienciu

1Clinica de Psihiatrie Eduard Pamfil Timișoara, Romania2Universitatea de Medicină și Farmacie Victor Babeș Timișoara, Romania

Introducere. Mamele care își alăptează copii prezintă numeroase beneficii atât pentru sănătatea lor, a copiilor și a societății. Depresia și anxietatea în rândul mamelor în primii 2 ani după naștere pot duce la consecințe grave atât pentru mamă cât și pentru copil. În ciuda faptului că sunt numeroase studii despre beneficiile alăptatului, asocierea acestuia cu depresia în perioada de după naștere rămâne incertă.Obiective. Lucrarea de față are ca obiectiv investigarea relației dintre apariția și severitatea depresiei și anxietății în perioada alăptării în rândul mamelor aflate în primii 2 ani de maternitate.Material si metodă. S-a studiat un lot de 315 de femei aflate în concediu de maternitate cu durata cuprinsa între 0 și 2 ani. S-au aplicat 2 scale de evaluare, simptomele depresive au fost evaluate cu scala PHQ9 iar pentru anxietate s-a folosit scala GAD7, precum și un chestionar pentru evaluarea duratei alăptării.Rezultate. Mamele care și-au alăptat copii în primele 6 luni prezintă scoruri de depresie și anxietate mult mai scăzute comparativ cu mamele care nu și-au alăptat copii în această perioadă. Mamele care au continuat alăptarea între 6 luni și 2 ani prezintă procente ale depresiei și anxietății aproximativ egale cu mamele care au întrerupt alăptarea copiilor.Concluzii. Alăptarea copiilor în primele 6 luni de viață se corelează cu scăderea indicilor de anxietate și depresie în rândul mamelor.Cuvinte cheie: depresie, anxietate, naștere, alăptare.

PATHOLOGY OF DEPRESSION AND ANXIETY AFTER BIRTH. CLINICAL PARTICULARITIES Introduction. Breast-feeding provides many health benefits for both, baby and mother, and also for society. Depression and anxiety among mothers in the first 2 years after birth can lead to serious consequences for both mother and child. Despite the fact that there are many studies about the benefits of breastfeeding, its association with depression during the after birth period remains uncertain.Objective. The present work aims to determine relationship between the occurrence and severity of depression and anxiety in the period of breastfeeding, among mothers who are in the first two years of maternity.Materials and methods. We studied a group of 315 women on maternity leave with duration between 0 and 2 years. We applied two evaluation scales (GAD7-generalized anxiety scale and PHQ9-depression scale) and a questionnaire to assess the duration of breast-feeding.Results. Mothers who have breastfed theirs babies within the first 6 months have lower scores of depression and

anxiety compared with mothers who have not breastfeeding theirs babies during this time. Mothers who continued breastfeeding from 6 months to 2 years shows percentages of depression and anxieties close to the scores of mothers who have disrupted breastfeeding children in this period.Conclusions. Breastfeeding babies in the first 6 months is correlates with lower indices of anxiety and depression among mothers.Keywords: depression, anxiety, birth, breastfeeding.

GRADUL DE ADRESABILITATE INTERCLINICĂ ÎN URGENŢĂ CĂTRE SERVICIILE DE PSIHIATRIE

1 1Flavia-Cătălina Cazan , Silviu-Andrei Tomulescu , 2Ramona-Liana Păunescu

1Spitalul Clinic de Urgență pentru Copii Cluj-Napoca, Romania2Universitatea de Medicină și Farmacie “Iuliu Haţieganu” Cluj-Napoca, Romania

Introducere. Asocierea dintre patologia psihiatrică şi cea somatică este tot mai frecventa indiferent de boala de baza. Consulturile interclinice solicitate în urgență in cursul gărzii de psihiatrie ocupă o mare parte, fiind în continuă creştere.Scop. Scopul studiului a fost de a evalua gradul de solicitare în urgenţă a serviciilor de psihiatrie, specialitățile medicale care solicită cel mai frecvent aceste servicii şi tipul de patologii care sunt adresate gărzii de psihiatrie Metodă. Studiul de faţă este unul de tip retrospectiv şi a fost realizat în Clinica Psihiatrie a Spitalului Clinic de Urgenţă Cluj-Napoca, pe o perioada de un an (01.06.2015-01.06.2016). Rezultate. Numărul total de solicitari a fost de 257 în perioada menţionată. Specialitățile care au solicitat cel mai frecvent consult psihiatric au fost: Neurologia (30%), Terapia Intensivă (28 %), Medicina Internă (15%), Chirurgie (10%). Restul de 17% au fost consulturi solicitate de alte specialități medicale si chirurgicale (Neurochirurgie, Dermatologie, Hematologie, Oftalmologie, Ortopedie, Chirurgie Plastica si Chirurgie Toracica, Ginecologie, Unitatea de Primiri Urgențe) Cele mai multe solicitări au implicat patologia afectivă (episoade depresive de diferita severitate şi tentative de suicid) urmată de tulburările legate de consumul de alcool (sevraje simple şi forme complicate) si sindroamele confuzive. Concluzii. Rezultatele studiului au demonstrat o prevalență ridicată a comorbidităților psihiatrice în bolile somatice, evidențiind necesitatea unei bune colaborări interdisciplinare şi a unei abordări integrative a pacienților. Cuvinte cheie: consulturi interclinice, psihiatrie, urgențe.

T H E A D D R E S S A B I L I T Y D E G R E E O F INTERDISCIPLINARY PSYCHIATRY SERVICES Background. The association between psychiatric and somatic pathology is increasingly common regardless of the underlying disease. The demand for emergency psychiatric services has rapidly increased and is growing.Purpose. The purpose of the study was to evaluate the degree of interdisciplinary psychiatric emergency

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services, the medical specialty most often requesting these services and the type of pathologies that are addressed by the psychiatric on call service.Methods. The study is retrospective and was conducted at the Emergency Psychiatry Clinic of Cluj-Napoca, for a period of one year (01.06.2015-01.06.2016).Results. The total number of requests was 257 during this period. The specialties from which psychiatric consultation requests were issued most often were: Neurology (30%), ICU (28%), internal medicine (15%), surgery (10%). The remaining 17% were consultations required by other medical and surgical specialties ( N e u r o s u rg e r y, D e r m a t o l o g y, H e m a t o l o g y, Ophthalmology, Orthopedics, Plastic Surgery and Thoracic Surgery, Gynecology, emergency department). The majority of requests involved affective disorders (depressive episodes of different severity and suicide attempts) followed by alcohol-related disorders (withdrawal syndrome) and confusion syndromes.Conclusions. The study results show a high prevalence of psychiatric comorbidities in medical and surgical patients, underscoring the need for better interdisciplinary collaboration and integrative approaches to the patient.Keywords: interdisciplinary approach, psychiatric emergencies.

P E R C E P Ț I A T R E C E R I I T I M P U L U I - P E R S P E C T I V A T U L B U R Ă R I I D E PERSONALITATE BORDERLINE

1 2 1Alina-Isabela Curt , Radu Dragomir , Cristina Ciocîrlan1Spitalul Clinic de Psihiatrie "Prof. Dr. Alexandru Obregia", București, Romania2Student an V, Universitatea de Medicină și Farmacie „Carol Davila”, București, Romania

Din cele mai vechi timpuri, oamenii de știință au fost interesaţi să definească noţiunea de timp şi să identifice un model care să ateste modul de percepţie a acestuia. Primul care a izbutit să identifice un tipar uman de percepţie a timpului a fost Michael Treisman, în 1963. Ulterior, mai mulţi psihologi şi neurocercetători i s-au alăturat în explicarea acestui fenomen. Din punct de vedere medical, interesul este foarte însemnat în analiza percepţiei trecerii timpului.În lucrarea de faţă, am încercat să realizăm o sinteză a celor mai importante studii clinice menite să pună în evidenţă felul în care unele caracteristici ale tulburării de personalitate borderline pot modifica percepţia trecerii timpului. Există o serie de ipoteze legate atât de aspectele neurobiologice, cât şi de cele psihologice referitoare la estimarea intervalelor temporale. Rolul lucrării este acela de a înțelege că unele acțiuni ale pacientului vin din raportarea diferită la timp şi că ceea ce până atunci ni se părea firesc, în cazul pacientului cu tulburare de personalitate borderline, firescul poate fi altfel. Astfel, vom creşte empatia noastră intelectuală şi afectivă, îl vom ajuta să se cunoască şi să se accepte, să-și perceapă limitele, să aibă simţul măsurii, să înţeleagă consecinţele acţiunilor lui, să fie aderent, constant și compliant la tratamentul medicamentos prescris și la psihoterapie.Cuvinte cheie: timp, empatie, tulburarea de personalitate borderline, percepția trecerii timpului, complianță terapeutică.

T I M E P E R C E P T I O N – B O R D E R L I N E PERSONALITY DISORDER PERSPECTIVESince ancient times, scientists have been interested in defining the concept of time and identifying a model for its perception. The first who was able to identify a pattern of human perception of time was Michael Treisman in 1963. Subsequently, several psychologists and neuroscientists joined in explaining this phenomenon. From a medical standpoint, there is a high interest in analyzing the perception of time.In this paper, we aimed to achieve a synthesis of the most important clinical studies designed to highlight the way in which certain characteristics of borderline personality disorder can alter the perception of time. There are a number of hypotheses with respect to both neurobiological aspects and the psychological, trying to explain the estimation on time intervals.The role of this study is to understand that some actions of the patient stem from different relations with time and that what until now seemed natural for patients with borderline personality disorder, may be normal in other ways. Thereby, we increase our intellectual and emotional empathy, we help the patient to know and accept him/herself, to levy limits, to have a sense of measure, to understand the consequences of his/her actions, to be adherent, consistent and compliant to the prescribed drug therapy and psychotherapy.Keywords: time, empathy, borderline personality disorder, time perception, therapeutic compliance.

EVALUAREA CALITӐȚII VIEȚII ȊN DEPRESIA UNIPOLARӐ ȘI BIPOLARӐ

1 2Ramona-Liana Păunescu , Silviu-Andrei Tomulescu 2Flavia-Cătălina Cazan

1Universitatea de Medicină și Farmacie “Iuliu Hațieganu” Cluj-Napoca, Romania2Spitalul Clinic de Urgență pentru Copii Cluj-Napoca, Romania

Introducere. In cadrul afecțiunilor psihiatrice, depresia reprezintă patologia cel mai frecvent asociată cu un nivel scăzut al calității vieții, aspect care conduce la o evoluție nefavorabilă cu consecințe nefaste asupra funcționării profesionale, familiale și sociale a pacienților depresivi.Scop. Scopul acestui studiu a fost de a compara calitatea vieții la pacienți diagnosticați cu episod depresiv din cadrul tulburării depresive recurente și a tulburării afective bipolare. Metodă. Studiul a inclus 70 de pacienți internați în Clinica Psihiatrie Cluj-Napoca în perioada septembrie 2014-iulie 2015. Evaluarea pacienților a fost făcută în contextul unui episod depresiv din cadrul Tulburării depresive recurente-TDR- (40 de pacienți) sau Tulburării afective bipolare-TAB- (30 de pacienți). Severitatea simptomatologiei depresive a fost evaluată clinic și cuantificată prin Scala de evaluare a depresiei Hamilton, versiunea cu 17 itemi. Pentru evaluarea calității vieții a fost utilizată Scala calității vieții-forma scurtă-WHOQOL-BREF.Rezultate. 80% dintre pacienții bipolari și 83,33% dintre pacienții diagnosticați cu TDR au prezentat episoade depresive severe la momentul evaluării. Scorurile medii transformate pentru domeniile evaluate de scala WHOQOL-BREF în cazul pacienților cu TDR au fost: pentru domeniul sănătății fizice 38,7;sӑnӑtate psihicӑ-

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34,7; relații sociale -35,3 și mediul de viațӑ-52,6. Pacienții depresivi bipolari au obținut pentru domeniul sănătății fizice-47,65; sănătate psihicӑ-46,37; relații sociale -43,35 și mediul de viațӑ-57,05.Concluzii: Pentru ambele tipuri de diagnostic, episodul depresiv determină afectarea calității vieții în toate cele patru domenii evaluate. Pacienții diagnosticați cu TDR au prezentat scoruri generale mai mici decât cele raportate pentru pacienții cu TAB. Scorurile obținute susțin rolul intervențiilor psihosociale de augmentare a calității vieții în cazul pacienților cu episoade depresive recurente.Cuvinte cheie: Calitatea vieții, depresie, tulburare afectivă bipolară.

ASSESSMENT OF THE QUALITY OF LIFE IN UNIPOLAR AND BIPOLAR DEPRESSION Introduction. Among psychiatric disorders, depression is the most common pathology associated with a poor level of quality of life, aspect that leads to a worse outcome with baleful consequences on the professional, familial and social functioning of depressed patients. Aim. The aim of this study was to compare quality of life during a depressive episode in patients diagnosed with Major Depressive Disorder and Bipolar Disorder.Method. The study included 70 patients admitted to the Psychiatric Clinic in Cluj-Napoca from September 2014 to July 2015. The assessment was performed during a depressive episode within Major Depressive Disorder –MDD- (40 patients) or Bipolar Disorder-BD-(30 patients). The severity of depressive symptoms was clinically evaluated and quantified with Hamilton Depression Rating Scale-17 items version. In order to evaluate the quality of life, we used WHOQOL-BREF scale. Results. 80% of bipolar patients and 83,33% of patients diagnosed with BD suffered from a severe depressive episode at the moment of assessment. The mean transformed scores for the domains evaluated with WHOQOL-BREF for MDD patients were: for Physical Health 38,7; Psychological Health - 34,7; Social Relations - 35,3 and Environmental Factors - 52,6. Bipolar depressed patients obtained for Physical Health - 47,65; Psychological Health - 46,37; Social Relations - 43,35 and Environmental Factors - 57,05.Conclusions. For both types of diagnosis, the depressive episode determines an impairment of the quality of life for all four domains assessed. Patients with MDD had lower general scores than those reported for patients with BD. The scores obtained sustain the role of the psychosocial strategies used in order to improve quality of life for patients with recurrent depressive episodes. Keywords: quality of life, depression, bipolar disorder.

MODELE DE AFECTARE A FUNCȚIILOR EXECUTIVE ÎN DEPRESIA UNIPOLARĂ ŞI BIPOLARĂ

1 2 2Bianca Suciu , Ramona-Liana Păunescu , Ioana Micluţia1Spitalul Județean de Urgență pentru Copii Cluj, Romania2Universitatea de Medicină și Farmacie „Iuliu Haţieganu” Cluj-Napoca, Romania

Introducere. Majoritatea studiilor au relevat faptul că deficitul cognitiv reprezintă un aspect important în multe boli psihiatrice, precum tulburarea afectivă bipolară și

depresia unipolară. În trecut, deficitul cognitiv a fost considerat ca parte a depresiei și s-a presupus că va dispărea odata cu ameliorarea simptomelor depresive sub tratament.Metodă. Studiul de față reprezintă o trecere în revistă a literaturii recente, având ca scop înţelegerea dimensiunii deficitului executiv în depresia unipolară și bipolară, precum și sublinierea diferenţelor dintre modelele de afectare a funcţiilor executive în cazul pacienţilor cu patologiile menţionate mai sus.Rezultate. Pacienţii depresivi unipolari și bipolari prezintă deficite cognitive în mai multe subdomenii din cadrul funcţiilor executive. Diferite subcomponente a funcţiilor executive sunt alterate în ambele tipuri de pacienţi depresivi, dar dificultăţi în menţinerea atenţiei apar specific în depresia bipolară, iar disfuncţionalităţi în comutarea atenţiei apar în patologia unipolară. Studiile descriu deficite clare în cadrul strategiilor de planificare și a proceselor de monitorizare, fiind caracteristic afectate în cadrul depresiei unipolare. De asemenea, acești subiecţi prezintă perseverări în răspunsuri, sugerȃnd deficite în comutare, necesitȃnd un timp prelungit și un efort cognitiv crescut pentru a îndeplini cerinţe ce implică un control al inhibiţiei sau flexibilitate cognitivă. Alte constatări sugerează că pacienţii depresivi bipolari tip I au o performanţă scăzută comparativ cu bipolarii tip II sau cei depresivi unipolari în cadrul funcţiilor executive, în special în luarea deciziilor, proces ce este considerat a fi un marker pentru patologia bipolară, fără diferenţe în cadrul celor două tipuri de subiecţi bipolari.Concluzii. Funcţiile executive reprezintă un termen ce include abilităţi cognitive de ordin superior cu deficite prezente în cadrul ambelor patologii, dar cu subtile diferenţe în cadrul tiparului de afectare.Cuvinte cheie: funcții executive, tulburare afectivã bipolarã, episod depresiv major.

PATTERNS OF IMPAIRMENT IN EXECUTIVE FUNCTIONS WITHIN UNIPOLAR AND BIPOLAR DEPRESSIONIntroduction. The majority of studies revealed that cognitive deficits are an important aspect in many psychiatric illnesses such as bipolar disorder and major depressive disorder. In the past, cognitive impairment was considered part of depression and it was expected to diminish as other mood symptoms improved with treatment.Methods. This study is based on the review of recent literature, performed in order to understand the dimension of executive impairment in unipolar and bipolar depression and also to highlight the differences between executive functions in patients with the above mentioned disorders.Results. Both unipolar and bipolar depressed patients display cognitive deficits in several cognitive domains within executive functions. Different subcomponents of executive functions are altered in both types of patients, but impairments in sustained attention appear specific in bipolar depression while dysfunctional divided attention is reported in unipolar disorder. Studies describe clear deficits in planning strategies and monitoring processes that are characteristically impaired in unipolar depressed patients. Also these subjects tend to make more perseverative responses suggesting set shifting deficits

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and moreover they require longer time and more cognitive effort in order to accomplish tasks involving inhibitory control or cognitive flexibility. Other findings suggest that bipolar I depressed patients perform worse than bipolar II depressed patients and unipolar depressed patients across all executive functions especially in the decision making process that is considered to be a trait marker for bipolar disorder with no differences between the two types of bipolar subjects.Conclusions. Executive functions represent a term that includes a higher order of cognitive abilities with deficits that are present in both disorders but display slightly different patterns of impairment.Keywords: executive functions, bipolar disorder, major depressive episode.

NIVELUL DE SATISFACȚIE PROFESIONALĂ AL MEDICILOR REZIDENȚI PSIHIATRI DIN CLUJ-NAPOCA

1 1Silviu-Andrei Tomulescu , Flavia Cătălina Cazan , 2Ramona-Liana Păunescu

1Spitalul Clinic de Urgență pentru Copii Cluj-Napoca, Romania2Universitatea de Medicină și Farmacie „Iuliu Haţieganu” Cluj-Napoca, Romania

Introducere. Gradul de satisfacție profesională în domeniul medical depinde de o serie de variabile cum ar fi consecințele actului medical, atmosfera de la locul de muncă, nivelul de colaborare inter-disciplinară și nivelul de recompensă.Scop. Scopul studiului a fost de a investiga gradul de satisfacție profesională în rândul rezidenților de psihiatrie din centrul universitar Cluj-Napoca.Metodă. Studiul a a inclus 40 de rezidenți de psihiatrie anii de studiu 1-4 cărora li s-a administrat chestionarul JSS, chestionar care cuprinde 36 de itemi regrupați în 9 subdomenii ce evaluează diferite aspecte referitoare la nivelul de satisfacție profesională (beneficii, nivelul de salarizare, condiții de muncă, etc.). Administrarea chestionarelor a fost cu caracter anonim.Rezultate. Analiza datelor a relevat un coeficient de satisfacție profesională de 58%. Cele mai mari valori au fost înregistrate pentru relația cu superiorii direcți (83,33%); relația cu colegii de muncă și natura muncii (69,44% ambele); la polul opus s-au situat oportunitatea de promovare (43,05%), beneficiile adiacente muncii (44,04%) și condițiile de muncă (46,62%). Scoruri intermediare au fost raportate pentru următoarele dimensiuni: nivelul de salarizare (50%), gradul de recompensă (53,96%) și comunicarea (62,3%).Concluzii. Rezultatele studiului au oferit o imagine generală asupra satisfacției la locul de muncă în cazul medicilor rezidenți psihiatri. Chiar dacă o serie de dimensiuni au obținut scoruri ridicate, media generală a scorurilor a fost de 58% fiind diminuată prin scoruri ce reflectă lipsa de satisfacție legată de condițiile de muncă (numărul crescut de documentație, reguli și proceduri ambigue) și de dificultatea parcursului profesional.Cuvinte cheie: satisfacție profesională, medici rezidenți, psihiatrie.

JOB SATISFACTION AMONG PSYCHIATRIC TRAINEES IN CLUJ-NAPOCAIntroduction. Job satisfaction level in the medical field relies on a series of variables such as the consequences of the medical act itself, the work environment, the degree of interdisciplinary cooperation and the level of reward.Aim. The aim of the study was to investigate the job satisfaction level among psychiatric trainees in the Emergency County Hospital of Cluj-Napoca.Methods. The study included 40 psychiatry trainees ranging from the 1st to 4th year who filled out the JSS questionnaire which comprises 36 items from 9 subdomains that evaluate various aspects related to job satisfaction (benefits, pay, work conditions, etc.). The questionnaires were anonymously filled.Results. Data analysis showed a job satisfaction quotient of 58%. The biggest values were recorded for the relationship with direct supervisors (83,33%); at the opposite end of the spectrum lie the relationship with work colleagues and the nature of work (both at 69,44%); promotion opportunity (43,05%), benefits (44,04%) and work conditions (44,62%). Intermediate quotients were reported for the following dimensions: pay (50%), contingent reward (53,96%) and communication (62,3%).Conclusions. The study results showed a general picture of the job satisfaction among psychiatric trainees. Even though a couple of dimensions had high values, the general satisfaction quotient was 58% being diminished by scores which reflect the lack of satisfaction regarding work conditions (too much paperwork, ambiguous rules and procedures) and the unclear picture of the career track.Keywords: job satisfaction, psychiatry, trainees.

INDEX AUTORIBalazs Oana Bădescu George Bărboianu Ruxandra Bernad Elena Bisu Ionela Blajovan Jeni Bounegru ElenaBourin MichelBran Mihai Brăileanu Daniela Bredicean Cristina Briciu Victor Bulat Geanina Bulgaru-Iliescu Diana Carp Eduard George Cazan Flavia-Cătălina Cărăuşu Ghenadie Chihai Jana Chiriță Anca Livia Chiriţă Roxana Chiriţă Vasile Ciocîrlan Cristina Cornuțiu Gavril Costea Gabriela Coşciug Ion Craina Marius Cristanovici Mădălina Culea Francesca Curt Alina-Isabela Davidson Michael

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Dehelean Liana Dehelean Mircea Dehelean Pompilia Deliv Inga Dragomir Radu Drut Iris Duică LaviniaEnătescu Ileana Enătescu Virgil Enătescu Virgil-Radu Fâlfan Mădălina Gheorghiu Valentin Gheorman Victor Giurgi-Oncu Cătălina Giurgiuca AnaGlăvan Daniela Gluhovschi Adrian Grozavu Alexandra Gutt Anca Hâncu Irina Homorogan Claudia Hromei Alexandra Ienciu Monica Iftodi Anca Iordan DanaLadea Maria Lăcustă Victor Lăzărescu Mircea Leț-Cornuțiu Oana Lupu MariaMadan Constanța Manea Mihaela Manea Minodora Marinescu Dragoș Marinescu Ileana Mălinescu Bogdan Micluţia Ioana Militaru Felicia

Moglan MariaMoldovanu Ion Negru George Nistor IonuțOnilă Diana Ovreiu Mădălina Papavă Ion Papavă Sorana Raluca Pădure Irina Pănescu Maria Păunescu Ramona-Liana Petru Raluca Ioana Pîrlog Mihai Cristian Popescu Anca Popovici Zsolt Radu Dania Andreea Ristea Silvia Rogoveanu Ion Romoșan Ana Romoșan Radu Rotaru Maria Spinei Larisa Suciu Bianca Șarpe Marcel Tătaru Nicoleta Tipa RalucaTomulescu Silviu-Andrei Trifu Simona Tudor Corina Tudose Aneta Maria Tudose CătălinaUdriștoiu Ion Udriștoiu Tudor Untu Ilinca Vasile Daniel Vulcănescu DragoșZamfirescu Luiza

ORIGINAL ARTICLES

THE CONTRIBUTION OF COGNITIVE-BEHAVIORAL THERAPY TO THE TREATMENT OF OBSESSIVE-COMPULSIVE DISORDER

1 2Cosmin O. Popa , Adrian Rus

1Lecturer, PhD, Clinical psychologist, CBT Psychotherapist, The Department of Ethics and Social Sciences, The University of Medicine and Pharmacy of Tirgu-Mures, Romania.2Assistant Professor, Ph.D., The Department of Social and Behavioral Sciences, Southwestern Christian University, Bethany, Oklahoma, USA.Corresponding author: Lecturer, Ph.D., Cosmin O. Popa, University of Medicine and Pharmacy of Tîrgu Mureș, Str. Gheorghe Marinescu, nr. 38, Zip code: 540142, Tîrgu-Mureș, Romania, e-mail: [email protected] May 10, 2016, Revised September 22, 2016, Accepted September 30, 2016

strong scientific support that recommends it as a stand-alone intervention or along with medication to treat the obsessive pathology.Keywords: obsessive-compulsive disorders, cognitive-behavioral therapy, the dorsolateral prefrontal cortex, exposure with response prevention, cognitive restructuring.

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Abstract: By the nature of specific clinical manifestations, obsessive-compulsive disorder is a unique psychiatric nosology, requiring a distinct approach to treatment. The currently existing debate in the psychiatric and psychotherapeutic medical environment refers to the type of treatment and the existing scientific validity at the moment. Cognitive-behavioral psychotherapy has a

As with many other psychiatric nosologies, the OCD etiopatogy is mostly made up of bio-psycho-social dysfunctions. Neuroimaging has found that the OCD involves a dysfunction located in the cortico-striatal-thalamic-cortical, with extensions in the amygdala, hippocampus, the anterior cingulate cortex and dorsolateral prefrontal cortex (4) (5) (6) (7) (8). At the level of neurotransmitters, a mutation was discovered in the hSERT gene, called I425V, resulting in a decrease in the level of serotonin in the neuronal synapse (9). Another biological aspect of TOC, consists of a specific increase in the intensity of symptoms of OCD or tics, in infants with a neuropsychiatric disorders, infections related to the presence of beta-hemolytic streptococci of group A (10) (11).

The theory of cognitive behavioral therapy (CBT), advances the idea that intrusive thoughts would be perceived by the patient as hazardous / catastrophic, resulting in the emergence of anxiety / depression. After all, everyone presents intrusive thoughts, but patients with OCD gives them a much greater significance and interprets them in a different sense. Social factors that contribute to the triggering / amplification of specific symptoms of this disorder are correlated with adverse life events, ie the distress caused by these events (12) (13).

CBT EFFICIENCY IN OCD AND THE REPRESENTATION BY NEUROIMAGING

Two meta-analyzes, first taking into account 19 studies conducted between 1980 to 2006, and the second taking into account 37 studies conducted between 1993 and 2014, measured the effect technique Exposition Prevention Response (ERP) compared to the overall effect of CBT. The results of the two meta-analyzes, and other studies indicate that CBT is effective in the treatment of OCD, thus revealing that the ERP and the Restructuring Cognitive (CR) technique are the most effective in

addressing the TOC (14) (15) (16). Both the standard and the intensive CBT are effective in addressing the obsessive pathology. However, a more recent meta-analysis that includes 17 clinical studies shows that the CBT intensive therapeutic effect is installed faster compared to the CBT standard, but after three months of treatment this difference disappears, both forms being equally effective (17).

However, if there is a drug-resistant OCD, several factors contribute to achievement of the positive therapeutic results through the use of psychotropic medication combined with CBT (18). Getting an effective therapeutic response may be adversely affected by the presence of a serious OCD symptomatology, comorbidity of depression, somatoform disorders of high intensity or low levels of insight (19). Psychotherapeutic cognitive behavioral intervention combined with antidepressant medication / antipsychotic contribute in such cases to decrease anxiety / depression, and not least of symptoms caused by OCD (20) (21) (22).

It is known that a combination of psychiatric medication with psychotherapy determines significant changes in the patient's brain (23). This is true, however, in the separate evaluation of the two therapeutic forms (24) (25) (26). Through direct influence on the brain caused by changes produced in the neuronal circuits with direct / indirect field of epigenetic effect of cognitive-behavioral therapy (CBT) on the brain, it may be considered in some cases, similar to psychotropic medication, more accurately, identical to a ,, epigenetic action drug "(27).

When referring to anxiety disorders, it appears that cognitive therapy (CT) acts mainly by gains in ventral and dorsal anterior cingulate cortex (ACC), the PFC median (mPFC), and not least the right cortex ventrolateral. Simultaneously, there is a decline in activity in the amygdala, hippocampus and medial temporal

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Cosmin O. Popa, Adrian Rus: The Contribution of Cognitive-Behavioral Therapy to the Treatment of Obsessive-Compulsive Disorder

cortex. The cause of these neurophysiological changes, is attributed to the use of CBT techniques that have direct impact on higher executive functions such as problem solving, self-referential thinking or cognitive spectrum re-evaluations (28) (29). In OCD, short cognitive-behavioral therapy (CBTs) had as a direct effect on brain, neuro-anatomical changes consisting of a decrease in thalamic activation correlated with increases in activity of the dorsal anterior cingulate cortex (Dhaka), all these changes are related to a decrease in the symptoms of OCD-specific (30) (31) (32) (33).OCD APPROACH BY THE CBT STANDARD

At the moment, there are a number of scientifically validated techniques specific to CBT, and that are effective in addressing the TOC, but not only. However it requires a greater influx of research in this area, given the complexity of clinical cases; it is important to correlate science with clinical practice and to find new ways, including the involvement of technology in the psychotherapeutic process (34) (35) (36) (37).

So the emergence of interactive platforms / websites to patients with OCD, contributes to the management of individual self-monitoring techniques such as obsessions and rituals, motivation, behavioral exposure, completing questionnaires / psychological test, etc. When this process involves a therapist, the effectiveness of these programs is evident (38). Involving technology in some psychiatric disorders, including OCD, is especially beneficial, not only in terms of efficiency but also economically, CBT being a viable choice in the field of psychopathology (39) (40). However in severe cases of OCD, standard CBT is recommended along with weekly meetings within the practice with direct applications in the patient's life.

Because OCD is a complex psychiatric nosology, involving obsessive rituals, compulsive behavior and also anxiety or depression behaviors in the treatment of severe cases is recommended a combined between SSRI augmented with cognitive behavioral therapy (41). The combination of CBT and SSRI is superior in therapeutic efficacy and in the TOC, or CBT monotherapy consisting of SSRI (42).

Simpson et. al (2013) show that augmentation of SSRIs and cognitive behavioral therapy consisting of exposure and prevention rituals (EX / RP) is superior in terms of therapeutic augmentation to SSRIs with Risperidone, the two forms of treatment being superior augmentation of SSRIs and placebo in OCD. SSRI efficacy and EX / RP consisted of a statistically significant reduction in anxiety, depression and OCD specific symptoms compared to SSRI and Risperidone, SSRI and placebo respectively. One of the conclusions of this study indicates that augmentation of SSRIs before the TOC and an antipsychotic is recommended by the CBT intervention consisting of EX / RP (43) (44). Exposure with response prevention (ERP) can be considered as first-line intervention in the TOC (45), so it is used in a large proportion of the cognitive-behavioral therapists (46).

However, unfortunately 20% of patients with OCD do not accept ERP, and another 25% give up this technique after the first meeting of exposure, so it is necessary to add antidepressant medication or more cognitive therapy interventions (47). Using specific techniques Cognitive Therapy (CT) / Rational Emotional

Behavioral Therapy (REBT), produce clinical improvement within tolerance uncertainty / decrease in response to stimuli anxiogenic, a change in the scope of dysfunctional beliefs / irrational faiths and more compliance to treatment in these patients (48) (49). Lastly, the role of cognitive techniques is to prepare the patient for behavioral exposures that will be performed within therapy (50).

Thiel et al. (2016) in a pilot study, applied a combination therapy of the Scheme Centered Cognitive Therapy (ST), and ERP which they called a STERP, with OCD patients resistant to standard CBT intervention. The results of this study showed that after 12 weeks of treatment, there was a significant remission of the symptom of the TOC in the patients included in the study. These results remained stable after six months from the end of the intervention, a period in which the applied intervention CBT and ERP, indicating that the ST in combination CBT and ERP can be an alternative to the TOC resistant to intervention with CBT standard (51).ACCEPTANCE AND COMMITMENT THERAPY IN OCD

Acceptance and Commitment Therapy (ACT) CBT is a psychotherapy belonging to the next generation (the third wave). By using philosophical pragmatism called functional contextualism (52) (53), ACT can be effective in addressing obsessional pathology, particularly due to increasing psychological flexibility (54). Psychological interventions consist of acceptance exercises or use of metaphors by the therapist in order to increase psychological flexibility of these patients. Other techniques consist in confronting mental obsessions and the awareness of emotions associated with these obsessions. Cognitive diffusion techniques serve to help the patient understand that obsessions and anxiety are directly connected more with his subjective experiences than the events of real life and that ultimately a thought is nothing more than a thought, in other words there is a big difference between thought and action (55). Beliefs / thoughts are not good or bad innately, but the interaction with stimuli and not least the significance attached to these stimuli lead to the division between positive or negative. If the patient with OCD responds to unexpected stimuli (intrusive thoughts / obsessions) as if they were real or would come from the real world, in other words map and territory are parts of a whole, the thought then becomes synonymous with the act / behavior (56). Another important aspect of the relational context (RFT), refers to the appearance of psychological discomfort by organizing the reports in a manner which causes irrational dysfunctional behavior. For example a patient may have the following intrusive / obsessive thought,, if I do not follow the same route every day to go to college, my mother will die ", this thought is followed by a sense that the patient attaches to the thought ,, if mom is going to die because I did not follow the same route every morning, it is a catastrophe and it is all happening just because of me. " Thought the fusion between action and through the patient sees the situation as it would have happened already or would be about to happen, meaning ,, hot cognition "is ,, is awful and it would be a tragedy / disaster if mother would die because of me ", this thought is followed by mental neutralization ,, will follow the same route every day to avoid this to happen to me , so that I do not feel guilty and

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accountable " (57), this thought generating anxiety, the final consequence is the emergence of rituals / compulsion. For this reason, before starting behavioral exposure techniques, the intolerance to uncertainty should be addressed directly and the thought-action fusion, through specific cognitive ACT diffusion techniques (58).

Perfectionism is a cognitive distortion that occurs generally because of the central beliefs or personality traits, which makes the patient using repetitive and contextual phrase must (59) (60). This must has an imperative connotation that contributes to increasing psychological inflexibility, including in patients with OCD. For instance if a person says ,, if you want to be a good student, you must go to class, "then must has a positive valence. Conversely if the same person says ,, I must be the best in all the examinations which I will sit in college, "then must has a negative value. The reason relates to the fact that nobody can be perfect and can not always succeed in all conditions. In fact, behind this must is the fear of failure, in other words the fear of liability (61) (62). Especially in obsessive pathology, the approach to perfectionism is by using cognitive restructuring techniques, the use of metaphors and not least using catastrophe avoidance techniques. Meanwhile, these techniques can be complemented with specific ACT techniques such as accepting, this resulting in reducing suppression of thought, and not activating the vicious circle of negative automatic thoughts / obsessions. Unconditional acceptance of oneself is an unevaluated system, uncritical and only refers to the highlighting of errors through isolated / contextual behaviors and acceptance of the fallible nature of the individual (63) (64).

Mindfulness site used as a therapeutic technique is a viable choice only when it is practiced in a practice, by a therapist, self-applied techniques of mindfulness do not have the desired effect in OCD (65).CONCLUSIONS

Due to the complexity and bio-psycho-social deficits present in OCD, this approach requires a medical-psychological type multidisciplinary clinical pathology. Depending on the severity of symptoms, the psychiatrist may choose as mono-therapeutic treatment option, which may consist in medication / CBT or a combination of both methods of treatment. Due to the fact that the effect of CBT on brain / neuro-transmitters is similar to the SSRIs, it can be used as a means of increasing and can replace large doses of medication / augmentation with another medication. This way the occurrence of specific side effects is avoided. In terms of CBT's the combination of ERP and cognitive restructuring, is the first-line intervention in the TOC, and in some cases they may be supplemented by ACT techniques such as cognitive acceptance and diffusion. Lastly, psychotherapeutic interventions may be supplemented by programs / web sites that contribute to facilitate the therapeutic process.

Abbreviations:OCD = Obsessive-Compulsive DisorderCBT = Cognitive-Behavioral TherapyERP =Exposure with Response Prevention CR = Cognitive RestructuringACT = Acceptance and Commitment TherapyEX / RP = Exposure and Ritual Prevention

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***

ORIGINAL ARTICLES

A COMPARATIVE SURVEY BETWEEN THE

LEVELS OF PERSONAL AND PERCEIVED STIGMA AMONG PROFESSIONALS WORKING IN THE PSYCHIATRIC CARE SYSTEM

1 2Raluca Ileana Nica , Mihail Cristian Pîrlog

1PhD Student, “Carol Davila” University of Medicine and Pharmacy Bucharest, Romania2PhD, Lecturer at the department of Psychiatry, University of Medicine and Pharmacy of Craiova, RomaniaReceived June 1, 2016, Revised July 15, 2016, Accepted July 28, 2016

respondents reported their personal attitudes (personal stigma) and perceptions of the attitudes of others (perceived stigma) in the community they work. Results: Personal stigma is lowest among the highest trained professionals (psychiatrists and psychologists) and highest among the lowest specialized personnel (carers and other professions). Perceived stigma is greater than personal stigma among all the professionals working in the psychiatric care system, the highest trained professionals have highest levels of perceived stigma and the lowest trained professionals have the lowest levels of perceived stigma.Conclusion: Stigmatizing attitudes are common to all professionals, the results suggest that there is a need to train better the staff according to its needs and to make more public awareness interventions tailored to the targeted groups. The current results provide a baseline for future interventions in order to decrease the stigma levels of professionals.

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Abstract: Background: In Romania there are very few 1national studies of the stigma associated with depression .

The psychiatric health care system is mainly concentrated on psychiatric hospitals with few ambulatory services offering very limited services, approximately 80% of the psychiatric staff is working in the psychiatric hospital. Coming from a 45-year period during which the psychiatry was only biological the Romanian population has started to discover and use the psychotherapeutic services provided by psychologists, a profession that was forbidden for a 20- year period during the communist time. This study seeks to compare the nature and extent of stigma among the professionals working in the psychiatric care system namely psychiatric hospital.Methods: A survey was conducted in professionals' group using the depression stigma questionnaire. The study comprised of a survey of 139 persons aged over 18 years, psychiatric staff working in the psychiatric hospital: psychiatrists, psychologists, nurses, carers and other professions (represented by social workers). The

BackgroundStigma attached to mental disorders is considered by health authorities, professionals and users of mental health

2 3 4 5services as one of the most important barriers to overcome in the community, constituting one of the four main directions of action of the Global Mental Health

6Action Plan . Stigma is a key component taken into consideration by a person that needs to seek professional help and very often it hinders the process of reintegration

7 8 9of the person in the community and is a source of 10psychological distress . Despite of its importance we have

few studies that try to understand stigma phenomenon and the society groups in which this phenomenon is wide spread and constitutes a real barrier for those who need support. An approach for understanding stigma and how the stigmatizing behavior forms among different society

11groups is to conduct comparative studies across these groups, especially among those whose members have a role and are important for facilitating access to care to those who need it. In this study we compare attitudes to depression of professionals from the psychiatric staff working in the psychiatric hospital. It is frequently assumed the fact the stigma appears less in the groups that have more information about depression and interact more frequently with people that are affected by depression. The limitations of this study refer to small selected sample that

is concentrated in two psychiatric hospitals. This paper is concerned with stigma and in particular, we test the hypotheses that stigma is less prevalent in highest trained psychiatric staff than the lowest trained staff, that the pattern of the stigma will differ in the three groups, that personal stigma will be less pronounced compared to perceived stigma in all three groups.MethodsSurvey questionnairePersonal and perceived stigma

12Stigma was measured using two 9-item scales [13]. The first scale assessed the respondent's personal attitudes towards the person with a depression diagnostic (Personal stigma). The second scale assessed the respondent's beliefs about other people's attitudes towards the person with a depression diagnostic (Perceived stigma). Both scales contained essentially the same statements, but differed in terms of whether they were aimed at personal attitudes or the perceived attitudes of others (12). An example of a statement from the Personal stigma scale was: 'Depression is not a real medical illness'. The corresponding statement in the Perceived stigma scale is 'Most people believe that depression is not a real medical illness'. (12) Ratings for each item of each test were made on a 5-point Likert scale (0 = strongly agree, 1 = agree, 2 = neither agree nor disagree, 3 = disagree, 4 = strongly disagree).

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The surveyA survey of 139 adults aged 18 years or over was conducted over the period September to October 2016. The target interviewees were persons working as psychiatric care staff: psychiatrists, psychologists, psychiatric nurses and carers as well as social workers from psychiatric hospital. The survey questionnaire was translated into Romanian and in order to verify the accuracy of the Romanian translation of the survey, questions were retranslated into English by an accredited translator who had not sighted the original version. As we have not used a case vignette for depression in the questionnaire we used in the translated questionnaire the syntagma ”diagnostic of depression” and not simply depression.Statistical analysisFor data analysis it was used the Microsoft Excel Program (Microsoft Corp., Redmond, WA, USA), together with XLSTAT for MS Excel (Addinsoft SARL, Paris, Franţa) şi programul IBM SPSS Statistics 20.0 (IBM Corporation, Armonk, NY, USA). The information obtained were stored in Microsoft Excel files and these were statistically processed in order to analyse the relationships between the demografic data and self and perceived stigma within each group as well as among the three studied groups.The complex statistical tests such as Z test for proportions, Square Chi test for independence, Kappa test of Cohen and B test of Kendall were performed using the commends from the XLSTAT module and/or with the SPSS program.In the present study for the analysis of the incidence tables we used the square Chi test in order to identify the distribution differences according to the important variables, as well as the Cohen's Kappa test and Kendall's tau B test for demonstrating the correspondences between the personal opinion of the respondents and what they think what is the opinion of the majority of people.Fot the square Chi test for testing the dependence there were calculated the results of the test for the dates from the incidence tables, these results being compared with the threshold value that indicates a significant dependence (95% or 99%) or a highly significant dependence (99.9%) between the two classification factors. We used the following interpretation of the p values, directly delivered by the program used for the statistical analysis :

· p < 0.05, significant rezult (S, 95% confidence that there is an asssociation between factors);

· p < 0.01, significant rezult (S, 99% confidence that there is an asssociation between factors);

· p < 0.001, highly significant result (HS, 99,9% confidence that there is an asssociation between factors);

· p > 0.05, insignificant result (NS, confidence that there is an asssociation between studied factors is lower than 95%, so the error to reject the hypothesis that the factors are independent is higher than 5%, threshold considered to high).Results

Taking into consideration the fact that at the country level the proportion of males is 48, 6% and 51,4% females we notice that there is a slight semnificative difference between these proportions and those calculated for the number of subjects from the study group, p value calculated with Z test for proportions being <0,0001. In conclusion, in the three study groups analysed the female weight is semnificantly higher then the female weight in the general population. This is well known especially within the health sector, in many countries women comprise over 75% of the workforce

Taking into account that the population at country level lives 46% in rural area and 54% in urban area we can notice that there is a highly significant difference between these proportions and those calculated for the respondents included in this group, the p value calculated through Z test for proportions being <0,0001. In conclusion, the percentage of the respondents from the urban area is much higher and this is explicable as most of the psychiatric hospitals are located in the urban area..

Raluca Ileana Nica, Mihail Cristian Pîrlog : A ComparativeSurvey Between the Levels of Personal and Perceived

Stigma Among Professionals Working in the Psychiatric Care System

LOT/GENDER WOMEN MEN Total

Psychiatric staff by gender (PS)

124 (89.21%)

15 (10.79%)

139 (100%)

Study group/Residence RURAL URBAN Total Psychiatric staff (PS)

21 (15.11%)

118 (84.89%)

139 (100%)

Sample SM Psychiatrist Psychologist Psychiatric nurse

Carer (Infirmier)

Other profession Total

Number of respondents 24 23 67 7 18 139

Percentage 17.27% 16.55% 48.20% 5.04% 12.95% 100.00%

Distribution by profession of the respondents from the psychiatric care system

The distribution by profession of the respondents reflects the situation of the actual composition of specialists in the psychiatric care system with a smaller number of psychologists and psychiatrists and higher number of nurses. For the purpose of this survey the professionals' group was

split in three subgroups:·Subgroup 1 consisting of psychiatrists and psychologists·Subgroup 2 consisting of nurses·Subgroup 3 consisting of carers (infirmiere) and other professions (social workers)

151


We found that there is a significant difference between the three subgroups in which we spilt the sample group of the professionals working in the psychiatric care system (square Chi p =0,033<0,05), the group formed by

psychiatrists and psychologists being the one that considered in the lowest measure (38,3%) that those who suffer from depression can snap out of depression if they want to. This shows that the high level training specialists

Answer S1 0 1 2 3 4 Total 1.Psychiatrists+ psychologists 5 (10.64%) 13 (27.66%) 17 (36.17%) 12 (25.53%) 0 (0.00%) 47 (100%) 2.Psychiatric nurse 1 (1.49%) 18 (26.87%) 16 (23.88%) 21 (31.34%) 11 (16.42%) 67 (100%) 3.Carers+other professions 0 (0.00%) 9 (36.00%) 3 (12.00%) 12 (48.00%) 1 (4.00%) 25 (100%)

Total 6 (4.32%) 40 (28.78%) 36 (25.90%) 45 (32.37%) 12 (8.63%) 139 (100%)

Statement 1: People with depression can snap out of it if they wanted.

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from the system of care consider depression as being a real illness that can be treated, at the other end being the nurses, carers and other professions that do consider that depression is a state that can be overcome using only the

personal will. We also notice that there is high percentage of psychiatrists and psychologists (36,17%) that do not have a position with regards to this statement..



Statement 10: Most people believe that people with depression could snap out of it if they wanted.

Answer S10 0 1 2 3 4 Total 1.Psychiatrists+ psychologists 3 (6.38%) 6 (12.77%) 15 (31.91%) 22 (46.81%) 1 (2.13%) 47 (100%) 2.Psychiatric nurses 1 (1.49%) 20 (29.85%) 17 (25.37%) 27 (40.30%) 2 (2.99%) 67 (100%) 3.Carers+other professions 0 (0.00%) 8 (32.00%) 5 (20.00%) 10 (40.00%) 2 (8.00%) 25 (100%)

Total 4 (2.88%) 34 (24.46%) 37 (26.62%) 59 (42.45%) 5 (3.60%) 139 (100%)

Comparing the answers of the three subgroups for the statement „Most people believe that people with depression could snap out of it if they wanted”, we noticed that there are no significant differences among the three subgroups, the result of the square Chi test being over the maximum threshold admitted, p=0,255>0,05. Analysing

the concordance between the personal opinion of the respondents and what they think that the opinion of the majority of other people is, we found that for the whole sample we have a weak concordance, the value of Kendall's tau-b coeficient being 0,365. The perceived stigma is higher in all the subgroups than personal stigma.

Statement 2: Depression is a sign of personal weakness.

Answer S2 0 1 2 3 4 Total 1.Psychiatrists+ psychologists 16 (34.04%) 20 (42.55%) 6 (12.77%) 5 (10.64%) 0 (0.00%) 47 (100%)

2.Psychiatric nurse 7 (10.45%) 35 (52.24%) 10 (14.93%) 14 (20.90%) 1 (1.49%) 67 (100%) 3.Carers+other professions 1 (4.00%) 9 (36.00%) 3 (12.00%) 12 (48.00%) 0 (0.00%) 25 (100%)

Total 24 (17.27%) 64 (46.04%) 19 (13.67%) 31 (22.30%) 1 (0.72%) 139 (100%)

153

The three subgroups have completly different views with regards to the statement that depression is a sign of personal weakness (square Chi p=0,0017<0,01), psychiatrists and psychologists not agreeing with this statement in proportion of 76,59%, compared to 40%

carers and other professions. This might show that people who do not have specialized training in the area tend to stigmatize more overlapping depression symptoms with character traits.


Statement 11: Most people believe that depression is a sign of personal weakness.


2.Psychiatric nurses 3 (4.48%) 26 (38.81%) 11 (16.42%) 26 (38.81%) 1 (1.49%) 67 (100%) 3.Carers+other professions 0 (0.00%) 4 (16.00%) 7 (28.00%) 13 (52.00%) 1 (4.00%) 25 (100%)

Total 6 (4.32%) 40 (28.78%) 26 (18.71%) 61 (43.88%) 6 (4.32%) 139 (100%)

The perceived stigma is higher among the psychologists and psychiatrists but the differences among the three groups of professionals are not statistically significant, the result of the square Chi test is p=0,167>0,05. This means that the perceived stigma among psychiatrists and psychologists is very high (55,32%), interestingly is almost the same among carers and other professsions

(56%) and lower among nurses (40,30%). Analying the concordance between the personal stigma and the perceived stigma, we notice that there is a weak concordance, the tau-b coefficent being 0,337, the perceived stigma being higher than the personal stigma in all three groups, the biggest difference being showed by psychiatrists and psychologists.

154

There are significant differences with regards to the statement „depression is not a real medical illness” (square Chi p=0,0052<0,01), 87,23% of psychiatrists and psychologists not agreeing with the statement compared to 74,62% of nurses and 68% of carers and other professions. There is little personal stigma shown at this statement by all three groups, the groups of psychiatrists and

psychologists exposing the lowest stigma and this situation could be explained by the superior training and information they have in the area. We have also to notice that also the other two subgroups have very low stigmatization leveles, this is due also to the fact that they work in a system where depression is treated as a medical illness.



Statement 3: Depression is not a real medical illness.

Statement 12: Most people believe that depression is not a real medical illness.



Total 35 (25.18%) 73 (52.52%) 11 (7.91%) 16 (11.51%) 4 (2.88%) 139 (100%)



Total 9 (6.47%) 42 (30.22%) 29 (20.86%) 55 (39.57%) 4 (2.88%) 139 (100%)

155

The answers for the perceived stigma in this case do not present a significant difference among the three subgroups but the result of the square Chi test p=0,067>0,05, was nearer to the threshold compared to the other statements, showing that there are bigger differences. The perceived stigma appear especially among psychiatrists and psychologists 53,19% and much lower in the other two

groups 40, 30% and 28%.Analysing the concordance between the personal opinion and what the respondents believe that is the opinion of the majority, we found no concordance (tau-b Kendall 0.068). This means that the difference between personal stigma and perceived stigma for this statement is very high.




Total 28 (20.14%) 70 (50.36%) 28 (20.14%) 11 (7.91%) 2 (1.44%) 139 (100%)

Statement 4: People with depression are dangerous.

For the statement „People with depression are dangerous” there were bigger differences than to the previous statements among the three subgroups, the result of the square Chi test being statistically highly significant p=0,0003<0,001. At this statement the groups of

psychiatrists and psychologists showed the highest level of disagreement (78,73%). It can be interpreted that depression. As an illness is not associated with an aggressive behavior.

Statement 13: Most people believe that people with depression are dangerous.



Total 11 (7.91%) 54 (38.85%) 42 (30.22%) 29 (20.86%) 3 (2.16%) 139 (100%)

The answers towards the perceived opinion of the general public regarding the statement „Most people believe that people with depression are dangerous” do not present significant differences among the three subgroups, the result of the square Chi test being p=0,538>0,05. The perceived stigma is higher among all the three groups

especially for psychiatrists, psychologists and nurses but stays almost the same for carers and other professions. For this statement the agreement between the personal stigma and perceived stigma is minimal(tau-b Kendall= 0,274).

156

For the statement „It is best to avoid people with depression so that you don't become depressed yourself” we identified a highly significant difference square Chi test p=0,0003<0,001, psychiatrists showing disagreement with the statement in a percentage of 93,56% compared to

88,06% of the nurses and 72% of carers and other professions. This might mean that people working in the system of care know that depression is not a communicable disease and that these people need support.



Statement 5: It is best to avoid people with depression so that you don't become depressed yourself.

Answer S5 0 1 2 3 4 Total 1.Psychiatrists+ psychologists 27 (57.45%) 17 (36.17%) 2 (4.26%) 1 (2.13%) 0 (0.00%) 47 (100.00%)

2.Psychiatric nurses 18 (26.87%) 41 (61.19%) 5 (7.46%) 3 (4.48%) 0 (0.00%) 67 (100.00%) 3.Carers+other professions 3 (12.00%) 15 (60.00%) 2 (8.00%) 5 (20.00%) 0 (0.00%) 25 (100.00%)

Total 48 (34.53%) 73 (52.52%) 9 (6.47%) 9 (6.47%) 0 (0.00%) 139 (100.00%)

157

The answers to the perceived stigma with regards to the opinion of the general public regarding the „contagious” aspect of depression do not show a significant difference among the three subgroups but the result of the square Chi test, p=0,067>0,05, was nearer to the significance threshold compared to the other statements. For this

statement there is no concordance between the personal stigma and the perceived stigma (tau-b Kendall= 0,067). The perceived stigma is higher than personal stigma in all three subgroups the highes level being shown by psychiatrists and psychologists 38,30% followed by nurses (26,87%) and carers and other professions (24%).


Statement 14: Most people believe that it is best to avoid people with depression so that you don't become depressed yourself.

Statement 6: People with depression are unpredictable.

A low percentage of 27,66% of psychiatrists and psychologists agreed with the statement „people with depression are unpredictable” compared to 49.26% of nurses that exposed the highest personal stigma and 44%

of carers and other professions, differences that are statistically significant, the result of the square Chi test being p=0,041>0,05.



Total 9 (6.47%) 55 (39.57%) 33 (23.74%) 39 (28.06%) 3 (2.16%) 139 (100%)



Total 9 (6.47%) 42 (30.22%) 31 (22.30%) 55 (39.57%) 2 (1.44%) 139 (100%)

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The perceived stigma linked to the impredictibility of the people diagnosed with depression shows differences among subgroups, even if higher than in other statements, the result of the square Chi test is very near to the maximum threshold of significance but going over it - p=0,063>0,05. The perceived stigma is remains highest among the nurses (53,73%) compared to the other

subgroups, very near to carers and other professions and to a high difference from psychiatrists and psychologists (38,37%).The degree of agreement between the personal and perceived stigma was statistically significant but weak to moderate, the value of Kendall's coefficient tau-b being 0,333.



Statement 15: Most people believe that people with depression are unpredictable.



Total 2 (1.44%) 33 (23.74%) 37 (26.62%) 64 (46.04%) 3 (2.16%) 139 (100%)

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At this statement regarding the fact that at a personal level the respondents would hide if they had depression the carers and other professions are the ones that would have the most stigmatizing personal attitude compared to other subgroups (12%) compared to nurses (5,97%) and psychiatrists and psychologists (4,27%). Nevertheless the

percentages are very low in all three subgroups showing the fact that they recognise depression as an illness that should be treated.Even if there are differences among the three subgroups, those are not statistically significant the square Chi test being p =0,493>0,05.


Statement 7: If I had depression I would not tell anyone.

Statement 16: If they had depression, most people would not tell anyone.

There are significant differences (p=0,012<0,05) between the answer given by the respondents from the three goups to the ststement „If they had depression, most people would not tell anyone” the psychiatrists and psychologists agreeing with this statement in a high percentage (57,45%), nurses disagree in procentage of de 49,25%,

and carers and other professions disagree only in a percentege of 24%. There is no agreement between persoanal opinion and perceived opinion regarding this statement the tau-b coefficient being 0,044. The perceived stigma is much higher than the personal stigma regarding this statement.



Total 16 (11.51%) 85 (61.15%) 29 (20.86%) 7 (5.04%) 2 (1.44%) 139 (100%)



Total 4 (2.88%) 29 (20.86%) 40 (28.78%) 58 (41.73%) 8 (5.76%) 139 (100%)

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We identified highly significant differences (p=0,0004<0,001) among the three subgroups regarding their personal opinion linke to the employment of the people with depression, the least stigmatizing being

psychiatrists and psychologists (87,24%), followed at a little distance by nurses (76,56%) and the highest personal stigma we find in the carers and other professions subgroup (56%).



Statement 8: I would not employ someone if I knew they had been depressed.

Answer S8 0 1 2 3 4 Total 1.Psychiatrists+ psychologists 18 (38.30%) 23 (48.94%) 5 (10.64%) 1 (2.13%) 0 (0.00%) 47 (100.00%)

2.Psychiatric nurse 13 (19.40%) 45 (67.16%) 7 (10.45%) 2 (2.99%) 0 (0.00%) 67 (100.00%) 3.Carers+other professions 1 (4.00%) 13 (52.00%) 6 (24.00%) 5 (20.00%) 0 (0.00%) 25 (100.00%)

Total 32 (23.02%) 81 (58.27%) 18 (12.95%) 8 (5.76%) 0 (0.00%) 139 (100.00%)

161

There were big differences in aswering to the statetment „Most people would not employ someone they knew had been depressed” square Chi test being p=0,014<0,05, especially among the distribution of answers for the carers and other professions group and the other two subgroups. The highest perceived stigma we found in the nurses

subgroup (40,30%) followed closely by psychiatrists and psychologists subgroup (34,04%). There is a significant but weak concordance between the personal stigma and the perceived stigma tau-b Kendall= 0,252 nad the personal stigma is lower than the perceived stigma in all three subgroups.


Statement 17: Most people would not employ someone they knew had been depressed.

Statement 9: I would not vote for a politician if I knew they had been depressed.

At the statement „I would not vote for a politician if I knew they had been depressed” there are no significant differences among the three subgroups square Chi test p=0,176 >0,05, the subgroup of carers and other

professions scoring the highest at the personal level stigma (28%) followed by nurses (22, 13%) and psychiatrists and psychologists (8,52%).



Total 7 (5.04%) 31 (22.30%) 53 (38.13%) 38 (27.34%) 10 (7.19%) 139 (100%)



Total 12 (8.63%) 72 (51.80%) 29 (20.86%) 17 (12.23%) 9 (6.47%) 139 (100%)

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Among the answers of the three subgroups for the statement „Most people would not vote for a politician if they knew they had been depressed” there are notstatistically significant differencesp=0,504>0,05, the distribution of anwers being more close than to the previous statements.

There is a significant concordance but weak to moderate between the personal stigma and the perceived stigma (tau-b Kendall= 0,386). Similar to the other 8 questions the perceived stigma is higher than the personal stigma in all three subgroups.



Statement 18: Most people would not vote for a politician they knew had been depressed.



Total 6 (4.32%) 28 (20.14%) 48 (34.53%) 42 (30.22%) 15 (10.79%) 139 (100%)

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ResultsPersonal stigma The results of the comparison between levels of stigma among the professionals working in the psychiatric care system are presented in Table 1. In general, personal stigmatizing attitudes were less common among the subgroup of the psychiatrists and psychologists than

among nurses and carers and other professions. Compared to carers and other professions nurses more frequently indicated that the person with depression: does not have a real medical illness and it is unpredictable, for the rest of statements the carers and other professions have the highest levels of personal stigma.


Table 1: Percentage of professionals working in the psychiatric care system, respondents who 'agree'(3) or 'strongly agree' (4) with each statement from the Personal stigma scale

Perceived stigmaTables 2 show the results for the perceived stigma set of questions from the perceived stigma scale. Overall, perceived stigma was substantial, with percentage of respondents endorsing a statement from the Perceived stigma scale ranging from 25,54% to 57,45% among the psychiatrists and psychologists subgroup that have the highest levels of perceived stigma to all statements except for the statement “Most people believe that depression is a sign of personal weakness” where carers and other professions score a little higher 56% compared to 55,32% and to the statetements” Most people believe that people with depression are unpredictable” and 'Most people would not employ someone if they knew they had been depressed” where nurses have highest scores 53,73% and 40,03%.LimitationsThis study has a number of limitations. First, relatively small number of respondents. Secondly, the survey is not a representative national survey, the respondents

coming from two psychiatric hospitals. Finally, the different organizational culture of the two institutions may reflect differences in interpretation of questions, and cultural factors that affect interviewee responses.

ConclusionGiven the high level of personal stigma among carers and other professions working in a psychiatric hospital it is necessary to evaluate what type of interventions can be employed so that the levels of personal stigma decrease. The same applies for the high levels of perceived stigma among the highest trained subgroup of professionals. Finally, the study reported here represents the first comparative survey of stigma among professionals working in the psychiatric system of care in Romania. The current work provides a baseline for tracking the level of stigma of professionals into the future. The information from this survey could provide valuable information to those who decide the antistigma strategies in the country.

Statement PP (%) PN (%) C+OP (%) People with depression can snap out of it if they wanted 25,53 47,76 52 Depression is a sign of personal weakness 10,64 22,39 48 Depression is not a real medical illness 8,51 17,91 16 People with depression are dangerous 6,39 5,97 24 It is best to avoid people with depression so that you don’t become depressed yourself

2,13 4,48 20

People with depression are unpredictable 27,66 49,26 44 If I had depression I would not tell anyone 4,26 5,97 12 I would not employ someone if I knew they had been depressed 2,13 2,99 20 I would not vote for a politician if I knew they had been depressed 8,52 22,39 28

Table 2: Percentage of professionals working in the psychiatric care system, respondents who 'agree'(3) or 'strongly agree' (4) with each statement from the Perceived stigma scale

Statement PP (%) PN (%) C+OP (%) Most people believe that people with depression can snap out of it if they wanted

48,94 43,29 48

Most people believe that depression is a sign of personal weakness 55,32 40,3 56 Most people believe that depression is not a real medical illness 53,19 40,3 28 Most people believe that people with depression are dangerous 25,54 20,9 24 Most people believe that it is best to avoid people with depression so that you don’t become depressed yourself

38,29 26,87 24

Most people believe that people with depression are unpredictable 38,29 53,73 52 If they had depression most people would not tell anyone 57,45 49,25 24 Most people would not employ someone if they knew they had been depressed

34,04 40.03 20

Most people would not vote for a politician they knew they had been depressed

42,55 41,79 36

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REFERENCES

1.Beldie A., den Boer, J.A., Brain C., et all, Fighting stigma of mental illness in midsize European countries, Soc Psychiatry Psychiatr Epidemiol (2012) 47 (Suppl 1):1–38 DOI 10.1007/s00127-012-0491-z.2.World Health Organization: Mental Health: New Understanding, New Hope. Geneva, World Health Organization; 2001.3.Hinshaw SP, Cicchetti D: Stigma and mental disorder: Conceptions of illness, public attitudes, personal disclosure, and social policy. Dev Psychopathol 2000, 12:555-598. 4.McNair BG, Highet NJ, Hickie IB, Davenport TA: Exploring the perspectives of people whose lives have been affected by depression. Med J Aust 2002, 176 Suppl:S69-765.Hocking B: Reducing mental illness stigma and discrimination - everybody's business. Med J Aust 2003, 178:S47-S48.6.http://www.who.int/mental_health/action_plan_2013/en/7.Wells JE, Robins LN, Bushnell JA, Jarosz D, Oakley-Brown MA: Perceived barriers to care in St. Louis (USA) and Christchurch (NZ): reasons for not seeking professional help for psychological distress. Soc Psychiatry Psychiatr Epidemiol 1994, 29:155-164.8.Corrigan PW, Edwards AB, Green A, Diwan SL, Penn DL: Prejudice,

social distance, and familiarity with mental illness. Schizophr Bull 2001, 27:219-225.9.Corrigan PW, Edwards AB, Green A, Diwan SL, Penn DL: Prejudice, social distance, and familiarity with mental illness. Schizophr Bull 2001, 27:219-225.10.Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L: On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav 1997, 38:177-190.11.Griffiths, K. M., Nakane, Y., Christensen, H., Yoshioka, K., Jorm, A. F., & Nakane, H. (2006). Stigma in response to mental disorders: a comparison of Australia and Japan. BMC Psychiatry, 6, 21. http://doi.org/10.1186/1471-244X-6-2112.Griffiths KM, Christensen H, Jorm AF, Evans K, Groves C: Effect of web-based depression literacy and cognitive-behavioural therapy interventions on stigmatising attitudes to depression: randomised controlled trial. Br J Psychiatry 2004, 185:342-349.13.http://www.who.int/hrh/statistics/spotlight_2.pdf

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ORIGINAL ARTICLES

TRENDS IN CHILD AND ADOLESCENT PSYCHIATRIC DIAGNOSES IN A ROMANIAN INPATIENT UNIT BETWEEN 1990 AND 2014

1 1,2 2 1Ilinca Mihailescu , Florina Rad , Cristina G. Anghel , Cornelia Paraipan , 1 1,3 4 3,4Lucia E. Andrei , Liana Kobylinska , Iorgu D. Matei , Mircea B. Matei ,

1,2Iuliana Dobrescu

1Department of Child and Adolescent Psychiatry, „Prof. Dr. Al. Obregia” Psychiatry Hospital, Bucharest, Romania2Department of Child and Adolescent Psychiatry, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania3Department of Physiology and Fundamental Neuroscience, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania4Department of General Psychiatry, „Prof. Dr. Al. Obregia” Psychiatry Hospital, Bucharest, RomaniaCorresponding author: Florina Rad, e-mail: [email protected], Tel: +40742069652Received September 2, 2016, Revised October 7, 2016, Accepted October 20, 2016

number of psychotic disorders was constant over time, mood disorders had peak frequencies in 2003 and 2014 and anxiety disorders has a twofold increase from 2007 to 2014.Conclusions. This study demonstrates a major shift in the patterns of mental health disorders diagnosed among children and adolescents at our clinic over the last 25 years. Defining the current mental health needs of young people and adjusting service delivery in child and adolescent psychiatric settings have become of great importance in recent years.Keywords: children, adolescents, mental health, psychiatric disorders

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AbstractObjective. This paper aims to describe trends in diagnostic data in discharged patients from a regional child and adolescent psychiatric inpatient unit in Romania, over a 25-year period (1990-2014).Method. Data on discharge diagnosis of the 30854 patients from the study timeframe were analyzed. Diagnostic formulations in the years prior to ICD implementation were converted into ICD-10 specific disorders/ class of disorders.Results. Results showed a significant increase in proportion of autism spectrum disorders and hyperkinetic disorders over time and a significant decrease of stress related, dissociative and somatoform disorders. The

According to the U.S. National Institute of Mental Health, over 20 percent (1 in 5) children, either currently or at some point during their life, have had a seriously debilitating mental disorder and about 13 percent of children ages 8 to 15 had a diagnosable mental disorder within the previous year (1). World Health Organization states that mental health disorders in children and adolescents are of great concern because of their high prevalence and the accompanying disabilities (2).

The Centaur project was the only systematic epidemiologic survey of child and adolescent psychiatric disorders conducted in Romania between 1981 and 1984, on a nationwide sample of 14812 subjects aged 10 months to 16 years. The study reported an overall point prevalence of 11.7% for any psychiatric disorder in children and adolescents and also assessed the individual prevalence of 90 psychiatric and neurological disorders, based on DSM-III and ICD-9 criteria (3). More recent, population-based representative data are not available in Romania, at this moment.

This paper aims to describe trends in diagnostic data of patients discharged from a regional child and adolescent psychiatric inpatient unit in Romania, over a 25-year period (1990-2014). METHODSetting

The present study was conducted in the Department of Child and Adolescent Psychiatry of the "Prof. Dr. Alexandru Obregia" Psychiatry Clinical

Hospital in Bucharest, Romania. The clinic is one of three university clinics of Child and Adolescent Psychiatry in the country and the largest one, with a total of 70 beds at present. The clinic functions as an inpatient unit for acute patients, who are admitted for continuous hospitalization or day hospitalization. The patients addressing the clinic are both inhabitants of the city of Bucharest (approximately 2103000 inhabitants) and the neighboring districts.

An important legislative change in this field, with consequences for the organization of the clinic took place in Romania in 1996, when the specialty called Infantile Neuropsychiatry was officially divided into two distinct medical specialties, Paediatric Psychiatry (Child and Adolescent Psychiatry) and Paediatric Neurology. The actual transition within the hospital with the full separation of psychiatric from neurological cases into two different departments took place gradually, until the year 2000. Thus, prior to this period, patients addressed the clinic either for a neurological or for a psychiatric issue, and only later on did the pathology become almost exclusively of a psychiatric nature. The neurological cases were excluded from the analysis performed in this study.Procedure and analysis

Data of of 39562 patients hospitalized in the clinic between 1990-2014 have been initially collected in the present study. Of these patients, 8708 were exclusively neurological cases and were therefore later removed from the analysis. Ultimately, 30854 patients with psychiatric

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Ilinca Mihailescu, Florina Rad, Cristina G. Anghel, Cornelia Paraipan, Lucia E. Andrei, Liana Kobylinska, Iorgu D. Matei, Mircea B. Matei, Iuliana Dobrescu Trends in Child and Adolescent Psychiatric Diagnoses in a Romanian Inpatient Unit Between 1990 and 2014

:

pathology, aged between 1 and 18, admitted as continuous hospitalization inpatients, were included in the study.

In 2009, the hospital introduced a computerized system for the manipulation and storage of patient information. Data for the patients who had been hospitalized before 2008 existed only on paper, in the clinical observation sheets and patient registers. Thus, an electronic database was initially created by the

transcription of patient data (age, gender, city, diagnoses upon discharge) for the patients who were admitted between 1990 and 2009. Clinical data of the patients who were admitted between the years 2012 and 2014 were provided by the Department of Medical Statistics within the hospital, through export from the computerized system of the hospital (Medical CM).

ICD - 10 F20 – 29 F30 – 39 F40, F41, F42 Diagnostic formulations before ICD

- hebephrenic/ paranoid schizophrenia - psychotic crises - psychotic state with discordant elements - paranoid catatonic syndrome - agitated hallucinatory-delusional episode - catatonic psychotic episode

- reactive depressive state - simple depressive

syndrome - manic syndrome - catatonic psychotic

episode on euphoric state - manic psychosis - bipolar affective

disorder- depressive/ manic episode/ manic decompensation

- hyperthimic delusional psychotic episode

- bipolar affective disorder with atypical elements

- anxious neurotic episode - polymorphic anxiety episode - acute anxious-depressive-

obsessive episode - anxious neurosis - anxious depression - anxious-depressive reaction - panic crises/ attacks - obsessive-phobic neurosis - obsessive-compulsive

syndrome - impulsive-obsessive syndrome - obsessive manifestations - obsessive crises

F43, F44, F45 F84 F90 - reactive states

- pubertal disturbances - adolescence crisis în family context - adolescence neurotic disturbances - reactivity disturbances în tense

environment - reactivity disorder with functional crises - conversion disorder - affection crises - polymorphic functional disturbances - non-convulsive loss of consciousness - functional reactivity changes/ elements - co-occurring functional features - demonstrative features - functional disturbances with tendency to

secondary benefits - hypocalcemia symptoms secondary

intesified - asthenic syndrome with atypical features - cenesthopathiccrises - psychogenic cephalalgic syndrome - functional cephalalgia - psychogenic migraine/ - transient cenesthopathic syndrome

- psychic delay with autistic features

- critical mental delay with autistic features

- autistic elements - autistic components - mild childhood autism - social interaction

difficulties psychomotor retardation, uneven appearance and specific features

- psychomotor instability - hyperkinetic syndrome with

aggressive behavior/ on sequelbackground

- mental delay with hyperactivity

- moderate instability - hyper excitability - agitation on hyperkinetic

background

F91 - behavior disorders

- behavior disturbances with a tendency to structuring

- fixed aggressive behavior disorder with mixed etiology

- non-aggressive/ aggressive, unsocialized/ socialilized, behavior disorder

- socialized conduct disorder with educational deficiencies

- aggressive conduct disorder on hyperkinetic background

- prebubertal behavior disorders - paroxystic oppositional manifestation - pathological oppositional crises

Table 1 Diagnostic formulations prior to the implementation of ICD

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For logistical reasons, data on admissions from the second half of 2009 and the years 2010 and 2011 could not be accessed and were therefore not included in the present study.

For the study of the evolution of pathology within the clinic, all the diagnoses upon discharge of the 30854 patients from the study period were introduced in the analysis. Since 2008, all diagnoses are coded using the ICD-10 (International Classification of Diseases) codes, due to the introduction of the DRG (Diagnostic-related group) in the hospital. Before 2008 however, due to the absence of a standardized taxonomic system of diseases, the diagnoses were highly flexible, lengthy, with influences derived from French and Russian schools of psychiatry and dependent on each doctor's experience and training. Moreover, the medical language used was often different from one doctor to another. Therefore, a major step prior to the analysis was to translate these diagnoses into the closest possible ICD diagnostic categories, by a team of professionals within the clinic. This process was a difficult one, and due to the fact that, in many cases, a specific ICD code for a certain diagnosis was not identified, for certain pathologies, the preferred method was to determine the diagnostic category only (e.g. for any mood disorder the F30-F39-mood (affective) disorders ICD-10 code was used).

Thus, the analysis of the evolution of the pathology within the clinic between 1990 and 2014 was focused on the following disorders or diagnostic classes: F20-29 (schizophrenia, schizotypal and delusional disorders); F30-30 (mood disorders); F40,F41 and F42 (anxiety disorders and OCD); F43, F44 and F45 (stress related, dissociative and somatoform disorders); F84 (pervasive developmental disorders –currently referred to as autism spectrum disorders); F90 (hyperkinetic disorders); F91 (conduct disorders). Table 1 contains relevant examples of diagnostic formulations the years preceding the introduction of ICD in the clinic.

Due to the difference in the total number of discharges with a psychiatric diagnosis per year (ranging from 852 in 1993 and 2567 in 2013), we defined the frequency of disorders using percentages instead of absolute values. Least-squares regression has been used to determine time trends in rates of disorders.

RESULTS Table 2 displays the frequencies (in percentages)

of the mental disorders in the clinic, for each of the years included in the analysis. For each year, the reported percentage represents the number of diagnoses upon discharge of a certain disorder out of the total number of patients with a psychiatric diagnosis admitted to the clinic that year.

Regarding psychotic disorders in the F20-F29 category (schizophrenia, schizotypal and delusional disorders), no significant fluctuations are observed throughout the study period (F(1,21)= .75, p= .39)(Table 3), with a frequency of 2.3% to 7.6% of all cases per year (Figure 1a). Affective disorders (Figure 1b) experience an upward trend in the 1990-2003 time period (r2= .76, F(1,12)= 39.7, p= .000), from 3.9% in 1990 to 13.9% in 2003, equal to a 3.5-fold increase in frequency. During the

following years affective disorders decreases in frequency, reaching 4.97% in 2009, with a subsequent increase after 2009 leading to a frequency of 10.3% in 2014.

Anxiety disorders (Figure 1c) have a minimum frequency of 2.8% in 1997 and 1998 and a maximum of 9.13% in 2014. The increase over the entire time period is a significant one (F(1,21)= 18.34, p= .000)(Table 3), with the largest increment observed between 2007 and 2014, when the proportion of anxiety disorder doubled. Regarding the stress related, dissociative and somatoform disorders a downward trend is observed, from a maximum of 23.6% in 1991, to 6.4% in 2013, translated into a four time reduction in the total number of cases over time (Figure 1d).

Autism spectrum disorders showed the highest increase during the 1990-2014 study period (r2= .80, F(1,21)= 86.2, p= .000)(Table 3). Thus, if in 1990 through to the year 2000 the frequency of ASD was 3-6% of the total number of cases admitted to the clinic in one year, the percentage grew to 17-22% in 2005 to 2007, only to reach 39-42% in 2012-2014 (Figure 2a). Therefore, the frequency of ASD in the clinic has increased 12-fold in 2014 when compared to 1990.

The second largest increase in frequency during the study period was observed for hyperkinetic disorders (Figure 2b). Between 1990 and 2002 the frequency of the diagnosis was relatively stable, with a mean of 7.6%. Starting the following year, however, the frequency of hyperkineti disorders began to rise from 10.4% in 2003 to 25.6% in 2008 and it reached 38-42% in 2012-2014 with a peak in 2012. This increase is significant throughout the entire study period study and the observed trend is almost linear between 2002 and 2014 (r2= .93, F(1,9)= 129.7, p= .000)(Table 3). Almost half of all cases were co-morbid with autism spectrum disorders (18.1% out of 38.8% in 2014).

Conduct disorders register a rise in frequency in 1990-2001, from 13.0% in 1990 to 21.9% in 2001 (r2= .67, F(1,10)= 20.5, p= .000). After reaching a maximum in 2001, the number of diagnoses within the group of conduct disorders began to decrease, reaching 11.9% in 2004 (r2= .86, F(1,10)= 66.8, p= .000) (Figure 2c).

Estimates based on averaging 3 consecutive years' data, at the beginning of the study period (1990-1992), in the middle (2001-2003) and at the end (2012-2014) reveals the following (Figure 3): the most common discharge diagnoses in 1990-1992 were stress-related, dissociative and somatoform disorders (21.1%), followed by conduct disorders (11.9%); in 2001-2003, conduct disorders reached a peak frequency, with a proportion of 19.1%, the number of stress related, dissociative and somatoform disorders start to decrease (17.6%) and mood disorders also reached their highest level through the entire study period (12.2%); between 2012 and 2014, autism spectrum disorders and hyperkinetic disorders show a significant increase, each of these attaining a proportion of 40% of all the cases, conduct disorders start to decrease, reaching a similar frequency to the one observed in 1990-2014 (11.6%) and the proportion of anxiety disorders rises to 7.4%

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Ilinca Mihailescu, Florina Rad, Cristina G. Anghel, Cornelia Paraipan, Lucia E. Andrei, Liana Kobylinska, Iorgu D. Matei, Mircea B. Matei, Iuliana Dobrescu: Trends in Child and Adolescent Psychiatric Diagnoses in a Romanian Inpatient Unit Between 1990 and 2014

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2012 2013 2014

F20-29 4.15 4.53 5.29 5.52 6.74 5.24 6.37 4.59 6.09 5.94 6.57 7.01 6.04 7.34 7.07 6.91 7.41 7.10 5.92 4.69 2.84 2.30 4.11

F30-39 3.97 4.53 7.53 7.16 9.38 6.52 7.80 11.4 11.2 8.86 9.65 10.6 11.8 13.9 9.69 9.96 8.64 7.60 7.67 4.97 8.78 6.27 10.3

F40,41,42 4.34 4.98 3.86 5.28 3.32 3.74 3.70 2.88 2.88 3.39 5.34 6.03 6.04 6.01 6.08 4.54 6.90 4.52 5.34 5.10 6.27 6.93 9.13

F43, 44,45 21.2 23.6 18.3 14.4 19.7 14.1 14.7 14.9 18.5 14.1 9.86 17.6 19.5 15.4 14.9 12.7 12.9 11.8 9.32 13.3 7.76 6.43 7.30

F84 3.41 3.38 4.39 6.10 5.67 3.96 3.08 3.24 5.13 4.90 5.85 5.79 9.47 10.6 14.3 13.3 17.4 20.1 22.9 24.2 39.6 42.5 42.2

F90 7.01 5.78 7.98 7.98 13.1 8.02 8.21 7.39 8.23 6.79 5.95 6.11 6.95 10.4 13.3 13.6 23.3 25.6 29.9 28.5 42.8 38.8 38.8

F91 13.0 10.2 12.4 15.4 19.0 16.5 14.8 15.2 18.8 16.9 19.7 21.9 18.9 16.4 18.7 16.4 16.7 15.3 13.5 13.9 10.9 12.2 11.9

Total (n) 1084 1125 1115 852 1023 935 974 1110 936 1061 974 1227 1309 1348 1414 1607 1551 1592 2060 725 2074 2567 2191

Tabel 2 Frequency (percentages) of mental disorders in the clinic between 1990 and 2014F20-29schizophrenia, schizotypal and delusional disorders; F30-30 mood disorders; F40, F41, F42 anxiety disorders and OCD; F43, F44, F45 stress related, dissociative and somatoform disorders; F84 autism spectrum disorders; F90 hyperkinetic disorders F91 conduct disorders

Linear trends

r2 F Sign.

Schizophrenia, schizotypal and delusional disorders 0.03 0.75 0.39

Mood disorders 0.04 0.93 0.34

Anxiety disorders and OCD 0.46 18.34 0.00

Stress related, dissociative and somatoform disorders 0.64 38.31 0.00

Aautism spectrum disorders 0.80 86.2 0.00

Hyperkinetic disorders 0.73 58.47 0.00

Conduct disorders 0.02 0.52 0.47

Tabel 3 Linear trends

Fig. 1 Time trends (1990 -2014) in schizophrenia, schizotypal and delusional disorders (a), mood disorders (b), anxiety disorders and OCD (c), stress related, dissociative and somatoform disorders (d)

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Fig. 2 Time trends (1990 -2014) in autism spectrum disorders (a), hyperkinetic disorders (b), conduct disorders (c)

Fig. 3 Pattern of diagnoses in 1990-1992 (a), 2001-2003 (b), 2012-2014 (c)

DISCUSSIONThe present study demonstrates a major shift in

the patterns of mental health disorders diagnosed among children and adolescents at our clinic over the last 25 years. Highlighting this change is of major significance, both for clinical practice and for the community. In clinical practice, this shift in pathology supports the need to optimize hospital facilities, including human resources (type and number of personnel, professional training), the assessment and monitoring tools and, last but not least, the therapeutic interventions. The results of this study also prove the need for the undertaking of epidemiological studies on general populations. Identifying and quantifying the current issues regarding the mental health of children and adolescents should lead to optimizing the specific mental health policies. This could be achieved through providing adequate training to professionals in the field, improving the welfare and educational systems and increasing the level of awareness among the general population (facilitating the addressability towards medical service providers and social mobilization).

One of the main results of this study is the

overwhelming increase in the number of Autism spectrum disorders, diagnosed among the patients in our clinic over the years, from 3,4% ASD diagnoses upon discharge in 1990 to 42% in 2014, translated into a twelvefold increase in frequency. This increase may be largely explained by the actual increase in the prevalence of the disorder, as reported worldwide. The CDC, in their 2014 Morbidity and Mortality Monthly Report states that “The global prevalence of autism has increased twentyfold to thirtyfold since the earliest epidemiologic studies were conducted in the late 1960s and early 1970s.” CDC's ADDM Network in 2014 reports that about 1 in 68 children (8 year-olds) has been identified with ASD (4). This new estimate is roughly 30% higher than the estimate for 2008 (1 in 88), roughly 60% higher than the estimate for 2006 (1 in 110), and about 120% higher than the estimates for 2002 and 2000 (1 in 150) (4). Another factor contributing to the high number of ASD patients in our clinic was the increase in addressability over the last years, due to the ASD awareness campaigns aimed for the general public. Other causative factors would be the reduced capacity of the outpatient network, both in the

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Ilinca Mihailescu, Florina Rad, Cristina G. Anghel, Cornelia Paraipan, Lucia E. Andrei, Liana Kobylinska, Iorgu D. Matei, Mircea B. Matei, Iuliana Dobrescu: Trends in Child and Adolescent Psychiatric Diagnoses in a Romanian Inpatient Unit Between 1990 and 2014

the actual number of professionals and the lack of specific assessment tools for ASD, as well as the mandatory yearly assessment of children suffering from ASD who benefit from disability allowance.

Another significant finding of this study was the rise in the number of diagnoses of attention deficit hyperactivity disorder, which began in 2003. Until 2003 the frequency of this diagnosis was relatively stable (at 7% per year). In 2008 however, almost 25% of the patients were diagnosed with ADHD and by 2014, this percentage rose to almost 40%. This trend could be partially explained by the increasing comorbidity of ADHD with ASD. Thus, in 2014, almost 45% of the ADHD diagnoses are found in children suffering from ASD. This result is consistent with the available studies in literature, which stipulate that 30% to 80% of ASD patients also suffer from ADHD (5-8). Moreover, there was also an increase in the rate of ADHD diagnosis in children without ASD, in the timeframe that was analyzed. This increase could be attributed to a greater knowledge of this disorder among professionals as well as an actual rise in the prevalence of ADHD in the general population. Up until the introduction and use of the DSM and the ICD diagnostic manuals in Romania, psychiatrists' awareness regarding this pathology (often called „psycho-motor instability” in the 1990's) was fairly low, and therefore the disorder often remained undiagnosed. Worldwide, the rate of ADHD prevalence among children aged 5 through 18 years, increased from 1.1% in 1990, to 2.8% by 1995 (9), reaching up to 5.29% in 2007 (10). In 2012, results of a meta-analysis on the prevalence of ADHD, generated estimates in children and adolescents, ranging from 5.9% to 7.1%, depending on the source of information for the diagnosis (11). Another major shift in the pathology from our clinic was the significant decrease in the diagnostic classes related to stress, conversion and dissociative disorders. In the present analysis, these disorders have been combined into a single group, because diagnostic formulations prior to the introduction of ICD coding did not allow for a clear distinction between each of these disorders. Still, in the 90's, diagnoses such as "functional disturbances / crises" or "reactivity disorder" accounted for approximately 20 % of all cases, compared to only 6-7% in 2012-2014. Knowledge regarding the epidemiology of these disorders among children and adolescents is limited, mainly because of variable case definitions, assessment instruments and study populations (12). The influences of the cultural environment, responsible for social learning, modelling and different ways of expressing distress play an important role in the development and course of these symptoms. It may be speculated that this form of expressing psychological distress may be more frequent in certain cultural environments, in individuals with lower socioeconomic status and lack of education, in individuals with a history of physical abuse or neglect in childhood. A study published in India in 1993 also found high rates for this pathology in children, of approximately 14% in outpatients and almost 30% among inpatients (13). Therefore, the high frequency of these disorders among patients in our clinic during the 90's could be explained by the poor level of economic development in our country in that time period, by the almost exclusively eastern influences in our culture (after almost 50 years of living

under a communist regime) and by the low level of significance attributed to the understanding and fulfillment of emotional needs in general, during those times.

The psychotic disorders category, including schizophrenia, schizotypal and delusional disorders registered a stable and relatively low frequency in our clinic, during 1990 through 2014. Worldwide, the onset of schizophrenia prior to the age of 13 is still considered rare, with an incidence lower than 1 in 10000 children (14), but up to 20% of adults with schizophrenia become ill before the age of 18 (15). Data regarding time trends in early onset schizophrenia are lacking. Affective disorders have fluctuated in frequency during the studied time period in our clinic, with a minimum of 4% of all cases in 1990 and two peak frequencies in 2003 (13%) and 2014 (10%). The degree to which these rises in frequency are real or not may be verified through future epidemiological national studies. A meta-analysis published in 2006 in the UK regarding time trends in child and adolescent depression concludes: „There is no evidence for an increased prevalence of child or adolescent depression over the past 30 years. Public perception of an 'epidemic' may arise from heightened awareness of a disorder that was long under-diagnosed by clinicians” (16). The prevalence rate of major depression in children and adolescents is estimated between 0.2% to 3.0% in the general population, and between 0.0% and 0.9% for bipolar disorders (17).This study is characterized by a number of limitations that must be considered when interpreting the findings. First, the reliability of converting former diagnostic formulations into ICD-10 disorders does not ensure accuracy. Second, only a few types of information about the patients were recorded in hospital registries, thus limiting the analysis that could be performed. Finally, as data from only one clinical setting were utilized, the results should not be interpreted as nationally representative.

This study highlights the changing profile of mental disorders in inpatient care, demonstrating the need to reevaluate services delivered to children and adolescents. These findings also emphasize the need for future epidemiological research to improve the knowledge about the state of child mental health at the national level. As evidence suggests that lifetime mental disorders first appear before the age of 18 years, collaborative efforts must be brought to the forefront, prioritizing the care of children and adolescents. Ethical standardsThis study was approved and conducted according to the procedures of the ethics committee of “Prof. Dr. Alexandru Obregia” Psychiatry Hospital. Patient data were obtained with the permission of the local ethics committee with respecting the current laws regarding data protection. This is a register-based research, the manuscript does not contain clinical studies. AcknowledgmentsThe authors thank for significant contribution in data collection to all their colleagues: Aiten Abzait, Cristian Adam, Iulia Badarau, Alexandra Buica, Diana Barbulescu, Paula Chicos, Iuliana Ciobanu, Ana Maria Ciuca, Malina Coman,Sabina Duta, Laura Gheorghica, Georgiana Grigore, Elena Iliescu, Hermina Ionescu,

171


Cristian Luhovschi, Andra Magalu, Andra Melescan, Giorgiana Mihai, Mirela Militaru, Ioana Mocanu, Georgiana Murariu, Stefan Olteanu, Cristian Popa, Oana Rus, Raluca Soanca, Andra Soos, Mihaela Sprinceana, Alina Stan, Mihaela Stancu, Madalina Toma, Georgiana Tocaci, Iulia Turtoi, Ioana ViziteuConflict of interestThe authors declare that they have no conflict of interest.

References 1. National Institute of Mental Health. Any Disorder Among Children. http://www.nimh.nih.gov/health/statistics/prevalence/any-disorder-among-children.shtml Accessed 25 March 20162. The World Health Organization. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and s o c i a l s e c t o r s a t t h e c o u n t r y l e v e l . 2 0 1 2 . http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_10-en.pdf?ua=1 Accessed 25 March 20163. Grigoroiu Serbanescu M, Christodorescu D, Cantilli L, Jost L, Nedelcu H. Epidemiology of child and adolescent psychiatric disorder in a Romanian nationwide sample. I. Age group prevalence. Rom J Neurol 1997; 37(I-2):85-94.4. CDC. Prevalence of autism spectrum disorders. Autism and Developmental Disabilities Monitoring Network, United States. MMWR. 2014, 63(SS02);1-21.5. Davis NO, Kollins SH. Treatment for co-occurring attention deficit/hyperactivity disorder and autism spectrum disorder. Neurotherapeutics 2012; 9:518–530. doi:10.1007/s13311-012-0126-9. 6. Andersen PN, Hovik KT, Skogli EW, Egeland J, Øie M. Symptoms of ADHD in Children with High-Functioning Autism Are Related to Impaired Verbal Working Memory and Verbal Delayed Recall. PLoS One 2013; 8(5): e64842. doi: 10.1371/journal.pone.00648427. Yerys, BE, Wallace GL, Sokoloff1 JL, Shook DA, James JD, Kenworthy L. Attention deficit/hyperactivity disorder symptoms moderate cognition and behavior in children with autism spectrum disorders. Autism Res 2009; 2(6): 322–333. doi: 10.1002/aur.103.

8. Lee DO, Opal Y. Attention-Deficit Hyperactivity Disorder Symptoms in a Clinic Sample of Children and Adolescents with Pervasive Developmental Disorders. J Child Adolesc Psychopharmacol 2006; 16(6): 737–746. doi:10.1089/cap.2006.16.737.9. Robison LM, Sclar DA, Skaer TL, Galin R. National Trends in the Prevalence of Attention-Deficit/Hyperactivity Disorder and the Prescribing of Methylphenidate among School-Age Children: 1990-1 9 9 5 . C l i n P e d i a t r 1 9 9 9 ; 3 8 ( 4 ) : 2 0 9 - 2 1 7 . d o i : 10.1177/00099228990380040210. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 2007; 164(6):942–48. doi: 10.1176/appi.ajp.164.6.94211. Willcutt EG. The prevalence of DSM-IV attention-defici t /hyperact ivi ty disorder: a meta-analyt ic review. Neurotherapeutics 2012; 9:490–99. doi: 10.1007/s13311-012-0135-812. Gerralda ME, Rask CU. Somatoform and related disorders. In:

thThapar A, Pine D (Eds) Rutter's Child and Adolescent Psychiatry, 6 edn. John Wiley & Sons, 2005, 1035-1054 13. Srinath S, Bharat S, Girimaji S, Seshadri S. Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993; 32(4):822-5. http://dx.doi.org/10.1097/00004583-199307000-0001714. Shaw P, Sporn A, Gogtay N, et al. Childhood-onset schizophrenia: a double-blind, randomized clozapine-olanzapine comparison. Arch Gen Psychiatry 2006; 63(7):721–730. doi:10.1001/archpsyc.63.7.721.15. Maloney AE, Yakutis LJ, Frazier JA. Empirical evidence for psychopharmacologic treatment in early-onset psychosis and schizophrenia. Child Adolesc Psychiatr Clin N Am 2012; 21(4):885–909. doi: 10.1016/j.chc.2012.07.011.16. Costello JE, Erkanli A, Angold A. Is there an epidemic of child or adolescent depression? J Child Psychol Psychiatry 2006; 47(12):1263-71. doi 10.1111/j.1469-7610.2006.01682.x17. Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of mental disorders in children and adolescents. Dialogues Clin Neurosci 2009; 11(1):7–20

***

AL-BATAINEH, M. Ruxandra: 45, 51, 86 ANDREI, E. Lucia: 165 ANGHEL, G. Cristina: 165 ARDELEAN, Mihai: 4, 59 BANU, C.M. Ruxandra: 11, 86 BARBILIAN, Alexandra: 55, 104 BARBU, E. Raluca: 104 BILCĂ, Monica: 1, 72, 99 BLAJOVAN, Jenica 39 BOSCAIU, Voicu: 89 BOTIȘ, A. Codruța: 81 BRAN, Mihai: 15 BUICU, Gabriela: 1, 4 CHIHAI, Jana: 75 CIORABAI, M. Eda: 15 DIACONESCU, V. Liliana: 51 DOBRESCU, Iuliana: 165 COZMAN C.M. Doina: 29, 89DOLFI, Alexandra: 15 DONCHEV, Toni: 11 DUICA, Lavinia: 15 GANEV, Iordan: 11 GIURGIUCA, Ana: 15, 89 HURMUZ, Marinela34, 39 JEICAN, I. Ionuț: 29 KOBYLINSKA, Liana: 165 KOSTADINOV, Krasimir: 11 LĂZĂRESCU, Mircea: 34, 39, 109 LUKACS, Emese1, 72 MANCHEV, Ivan: 11 MANCHEV, Lachezar: 11 MANCHEVA-GANEVA, Velina: 11 MANEA, Mihnea: 15, 86

MARINESCU, Ileana: 15, 86 MARINESCU, Victor: 15 MARIȘ, Adina: 72, 99 MATEI, B. Mircea: 165 MATEI, D. Iorgu: 165 MATEI, P. Valentin: 15, 45, 51, 86 MICLUȚIA, V. Ioana: 81 MIHAILESCU, I. Alexandra: 45, 51MIHAILESCU, Ilinca: 165 MIHALACHE, A. Diana: 15MIHALCEA, Diana: 15 MITEA, A. Iulia: 15 NICA, I. Raluca: 8, 75, 149 NIREȘTEAN, Aurel: 1, 72 NIREȘTEAN, Tudor: 4, 72, 99 PARAIPAN, Cornelia: 165 PARASCHIV, L. George: 11, 15, 86 PAVEL, G. Ioana: 15 PÎRLOG, C. Mihai: 8, 11, 15, 75, 86, 149 POKORNY, Vasile: 1POPA, O. Cosmin: 4, 145 PRADA, I. Gabriel: 86 PRELIPCEANU, Dan: 15, 55, 104 PURNICHI, Traian: 11, 15, 45, 51, 86 RACOS – SZABO, Elisabeta: 21 RAD, Florina: 165 RUS, Adrian: 145 SABĂU, I. Aurora: 94SOREL, Eliot: 69 STANIA, Bogdan: 15 SZÁVA, Iringó: 21 TIPA, Raluca: 89 TODORAN – BUTILA, Anamaria: 21

Index of Authors

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Submitted manuscripts are screened for completeness and quality of files and will not enter the review process until all files are satisfactory. The Secretariat will announce the corresponding author about the receipt and the status of the manuscript.

Manuscripts and all attached files should be submitted in electronic form and on paper.The electronic form should be submitted, either on compact disk or by e-mail to: [email protected]. It is

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The manuscript should be accompanied by a cover letter including:- the statement on authorship,- the statement on ethical considerations,- the statement on financial disclosure.Manuscripts are received with the understanding that they have the approval of each author, are not under

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All named authors should meet the criteria for authorship as stated in the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication” issued by the International Committee of Medical Journal Editors ( ): “Authorship credit should be based on 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3. […]”.

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If the scientific project involves human subjects or experimental animals, authors must state in the manuscript that the protocol has been approved by the Ethics Committee of the institution within which the research work was undertaken. A statement of informed consent for human investigation should be made in the text, along with the name of the institutional review board that approved the study protocol. Authors must ensure that patient confidentiality is in no way breached. Do not use real names, initials, or disclose information that might identify a particular person without informed consent for publication. When clinical photographs of patients are submitted, consent by the patient must be obtained prior to submission of the article and is the responsibility of the author. The editors reserve the right to reject a paper on ethical grounds. All authors are responsible for adhering to guidelines on good publication practice.

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A submitted manuscript will be acknowledged and assigned a manuscript number, which is to be used in all further correspondence. Manuscripts are reviewed and given a priority based on their originality, importance of the findings, scientific merit and significance for the field, interest to readers, lucidity, and suitability for publication. Manuscripts with insufficient priority for publication are rejected promptly. Other manuscripts are sent to expert consultants for peer review. The existence of a manuscript under review is not revealed to anyone other than peer reviewers and editorial staff. Peer reviewers remain anonymous and are expected to maintain strict confidentiality. After the review process has been completed, authors will be informed by mail of the Editor's decision.

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acknowledgements. b) Material and methods have to be described in enough detail to permit reproduction by other teams. The

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INSTRUCTIONS FOR MANUSCRIPTS SUBMITTED IN ELECTRONIC FORMAT

VERY IMPORTANT: All manuscripts intended for publication will be subject to peer-review by a committee of experts which assesses the scientific and statistical correctness of articles submitted. The committee receives the manuscripts without knowing the authors' name and proposes possible changes, which will be transmitted to the authors by the medium of Editorial Board. The authors have the obligation to oversee the text in English language with the help of a professional translator.

- Reference to a journal publication: Vraşti R, Matei VMI. The crisis centre in Romania. Eur J Psychiat 2002; 29:305-311.Reynolds CF, Frank E, Perel JM et al. Treatment of consecutive episodes of major depression in the elderly. Am J

Psychiat 1994; 151(12):1740-3.- Reference to a book:

Vrasti R. The crisis centre in psychiatry. Toronto, London: Academic Press, 1993, 26-52.- Reference to a chapter in an edited book:

Schuckit MA. Alcohol-Related Disorders. In: Sadock BJ, Sadock VA, Ruiz P (eds). Comprehensive Textbook of Psychiatry. Philadelphia: Lippincott Williams and Wilkins, 2009, 1268-1287.

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REVISTA ROMÂNĂ DE PSIHIATRIEASOCIAŢIA ROMÂNĂ DE PSIHIATRIE ŞI PSIHOTERAPIEProf. Dr. Dan PRELIPCEANUClinical Hospital of Psychiatry “Prof. Dr. Alexandru Obregia”Şos. Berceni 10, sector 4, 041914 BucureştiTel./Fax: +40-21-334.84.06E-mail:

Contact: Viorel Roman – web editorE-mail: Tel. +40-21-334.84.06

- print edition - online edition

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ROMANIAN JOURNAL

OF PSYCHIATRY

APR

CONTENTS

t o ai t 149

ABSTRACTS - PSYCHIATRY AND MENTAL HEALTH NATIONAL CONFERENCE, CRAIOVA, 05-08 OCTOBER, 2016 115

REVIEW ARTICLES& o t t o 145

ORIGINAL ARTICLES &

&

INDEX OF AUTHORS 172

INSTRUCTIONS FOR AUTHORS 173

Romanian Journal of Psychiatry and Psychotherapy is recognized in Romanian National Council for Scientific Research in Higher Education, starting with January 2010, at B+ category

Romanian Journal of Psychiatry and Psychotherapy is indexed in the international data base Index

Copernicus – Journal Master List, starting with 2009. Ż

Doctors subscribed to this journal receive 5 CME credits / year. Scientific articles published in the journal are credited with 80 CME credits / article.

The Contribution f Cognitive-behavioral Therapy o he Treatment f Obsessive-compulsive Disorder

Cosmin O. Popa, Adrian Rus

A ComparativeSurvey Between he Levels f Personal nd Perceived

Stigma Among Professionals Working n he Psychiatric Care System Raluca Ileana Nica, Mihail Cristian Pîrlog

Trends in Child and Adolescent Psychiatric Diagnoses in a Romanian Inpatient Unit Between 1990 and 2014

Ilinca Mihailescu, Florina Rad, Cristina G. Anghel, Cornelia Paraipan, Lucia E. Andrei, Liana Kobylinska, Iorgu D. Matei,

Mircea B. Matei, Iuliana Dobrescu

165

Ż

www.romjpsychiat.ro

EDITOR-IN-CHIEF: Dan PRELIPCEANUCO-EDITORS: Dragoş MARINESCU Aurel NIREŞTEAN

ASSOCIATE EDITORS:Doina COZMANLiana DEHELEANMarieta GABOŞ GRECUMaria LADEACristinel ŞTEFĂNESCUCătălina TUDOSE

Executive editor: Valentin MATEI

STEERING COMMITTEE:Vasile CHIRIŢĂ (Honorary Member of the Romanian Academy of Medical Sciences, Iaşi)Michael DAVIDSON (Professor, Sackler

School of Medicine Tel Aviv Univ., Mount Sinai School of Medicine, New York)

Virgil ENĂTESCU (Member of the Romanian Academy of Medical Sciences, Satu

Mare) Ioana MICLUŢIA (UMF Cluj-Napoca)Şerban IONESCU (Paris VIII Universiy, Trois-

Rivieres University, Quebec)Mircea LĂZĂRESCU (Honorary Member of the

Romanian Academy of Medical Sciences, Timişoara)Juan E. MEZZICH (Professor of Psychiatry

and Director, Division of Psychiatric Epidemiology and International Center for Mental Health, Mount Sinai School of Medicine, New York University)

Sorin RIGA (senior researcher)

Eliot SOREL (George Washington University, Washington DC)

Maria GRIGOROIU-ŞERBĂNESCU (senior researcher)

Tudor UDRIŞTOIU (UMF Craiova)

Teodor T. POSTOLACHE, MD (Director, Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore)

Dan RUJESCU (Head of Psychiatric Genomics and Neurobiologyand of Division of Molecular and Clinical Neurobiology, Department of Psychiatry, Ludwig-Maximilians-University, Munchen)

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