Psihiatrie

SPECIAL ARTICLES CARDIOVASCULAR COMORBIDITY ASSOCIATED WITH SCHIZOPHRENIA SPECTRUM DISORDERS Veronica Ruşanu, Roxana M Stoean, Mirela Manea, Bogdan E Patrichi, Alina Frunză Abstract : Cardiovascular disease is a relatively common comorbidity in patients with major psychiatric disorders. The mortality rate of people with schizophrenia spectrum disorders is described as excessive and premature. This is due to the major psychiatric disorders, side effects of psychotropic medication and improper lifestyle, cardiovascular disease. Once developed the cardiovascular diseases, patients with schizophrenia have a reduced capacity to adhere to secondary prevention programs, such as exercise and weight control through proper diet. Key words: cardiovascular disease, schizophrenia, mortality, antipsychotics. “ACKNOWLEDGEMENT: This paper is supported by the Sectorial Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and Romanian Government under the contract number POSDRU/159/1.5/S/137390/” Schizophrenia spectrum disorders (schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder) is associated with numerous health problems. Patients with these conditions are prone to poverty, institutionalization and social isolation. They have great difficulty in taking care of themselves, they have inappropriate lifestyle because of sedentary, inadequate nutrition, smoking and excessive consumption of alcohol or other substances. There is also a socialprofessional degradation while the disease advances. Most of the patients live in poverty, are socially isolated, are unemployed or provides work below the level of their parents, are married or divorced, have limited social contacts outside the family, fail to achieve educational goals. Often, there might occur a significant cognitive impairment that persists during periods of remission of psychotic symptoms and has a significant influence on the ability of self-care and daily functioning. The mortality rate of people with schizophrenia spectrum disorders is described as excessive and premature (1). It is considered that the death of these patients may occur with 10-25 years earlier, compared to the general population (2). Men with schizophrenia or related disorders die with 20 years earlier, women with 15 years earlier, compared with those without major psychiatric disorders. Suicide can be a major cause for premature death, the remaining causes of death being due to cardiovascular disorders, diabetes, pulmonary disease as a result of excessive smoking (approximately 70% of patients diagnosed with psychotic disorders smoke) (3). Patients with these conditions have an increased risk of obesity (1.5-2 times higher), diabetes mellitus (2 times higher), dyslipidemia (5 times higher), smoking (by 2-3 times more) compared to people who do not suffer from these conditions (4). Most antipsychotic drugs increase the risk of comorbidities, leading to weight gain, elevated blood sugar, cholestatic liver diseases (5). It is thought that at least 10% of the people who take antipsychotic drugs for a long time, shall develop type 2 diabetes mellitus, two times more than the general population. Also, it is thought that there is a common genetic vulnerability, between psychosis and the risk of diabetes. An observational study conducted by Smith DJ, et al, on a sample representing about a third of the population of Scotland, tried to identify the most common comorbidities associated with schizophrenia and related psychotic disorders. The highest prevalence was obtained for viral hepatitis, constipation or Parkinson's disease. Other somatic diseases with high prevalence in patients with disorders like schizophrenia compared with the population undiagnosed with major psychiatric disorders were diabetes, COPD, chronic pain, epilepsy, irritable 1 Psychiatry MD, PhD Student in Psychiatry, Bucharest Emergency Hospital Psychiatry MD, Sf. Pantelimon Emergency Hospital, Bucharest Senior Psychiatrist MD, PhD, Professor at “Carol Davila” University of Medicine and Pharmacy, Bucharest Senior Psychiatrist MD, PhD at “Carol Davila” University of Medicine and Pharmacy, Bucharest Resident in psychiatry, PhD Student in Psychiatry, Assistant Professor at “Carol Davila” University of Medicine and Pharmacy, Bucharest 1 Veronica Ruşanu, Roxana M Stoean, Mirela Manea, Bogdan E Patrichi, Alina Frunză: Cardiovascular Comorbidity Associated With Schizophrenia Spectrum Disorders bowel syndrome. Surprisingly, cardiovascular disease, high blood pressure, atrial fibrillation, coronary disease and cancer had a lower prevalence in those with schizophrenia compared with those without psychiatric disorders, although many other studies see these as some of the causes of premature death in this population (3). According to the author, this may be due to the fact that patients with major psychiatric disorders either do not see the general practitioner of the cardiologist due to a low acknowledgement of the cardiovascular symptoms or their wrong interpretation, either because, despite the frequent contacts with medical specialists, are less investigated, monitored and they are not treated with the same attention and consideration as the patients without related psychotic disorders (3). The authors of this study believe that the low prevalence of high blood pressure is also due to the hypotensive effect of psychotropic medication. Also based on the adverse effects of antipsychotics may explain the greater percentage of patients with constipation or Parkinson's disease (anticholinergic effects, namely neuroleptization effect, parkinsonian syndrome). In the general population, QTc interval prolongation is associated with increased cardiovascular mortality with sudden death, especially in patients who have had a history of diabetes mellitus and cardiovascular diseases. In patients with psychiatric disorders, the QTc interval prolongation is a consequence of antipsychotic treatment, although schizophrenia is associated with prolongation of the OTC interval even in the absence of psychotropic medication. To this is added the presence of metabolic syndrome and diabetes mellitus, frequently encountered in patients with schizophrenia spectrum disorders and further contribute to increased cardiovascular mortality within this population. Alcohol consumption, physical inactivity, poor adherence to treatment plan required for those with cardiovascular disease, the presence of other comorbidities determines an additional negative influence. A comparative metaanalysis performed by AJ Mitchell and Lawrence D, published in 2011, points out that after an acute cardiovascular event, patients with a major psychiatric disorder experience a 14% lower rate of invasive coronary interventions (47% in those with schizophrenia) and have an 11 percentage of mortality (6). Once developed the cardiovascular disorder, patients with schizophrenia have a reduced capacity to adhere to secondary prevention programs, such as exercise, weight control through proper diet, even weight loss. A study published by Kurdyak P et al in 2012 had as main objective to compare mortality upon 30 days of hospital discharge after acute myocardial infarction among patients with schizophrenia and those without. A secondary objective has been to follow the process of patient care (visits to the cardiologist and procedures performed in the first 30 days after myocardial percutaneous transluminal coronary or revascularization intervention by coronary bypass). 71668 subjects were included in the research, including 862 diagnosed with schizophrenia. The study showed an increase in mortality in patients with schizophrenia and myocardial infarction within 30 days of discharge after the latter. With 56% higher than for subjects with infarction, but undiagnosed with schizophrenia. People with schizophrenia received 2 50% less adequate cardiac procedures or care compared with people without this psychiatric disorder. Fewer than 1 in 4 patients with schizophrenia received interventional cardiology procedure and only 12 of 100 had cardiac check-ups within 30 days of discharge after an acute myocardial infarction (7). An observational study coordinated by the Finnish Suvisaari J investigated the prevalence of coronary heart disease and myocardial infarction in people over 30 years, 71 diagnosed with psychotic disorders in a sample of over 8,000 persons, considered representative of the population of Finland, monitoring EKG changes, mainly the prolongation of the OTc interval, physical examination data and meaningful information from patient observation charts. Only 71.2% of people with psychotic disorders and coronary heart disease reported having been diagnosed with heart disease and were able to report if they followed cardiology treatment, compared with only 88.5% of patients with coronary artery disease. The main conclusion of this study is that patients with schizophrenia are associated with more severe forms of coronary artery disease, the presence of Q infarction waves on the ECG and believes that monitoring the signs and symptoms of coronary artery disease should be more active in people with psychotic disorders , in particular schizophrenia (8). Two studies conducted by Curkendall SM and McDermott S, respectively, indicated an incidence, prevalence and an increased risk of congestive heart failure but did not reveal a statistically significant increase in the risk, prevalence or incidence of coronary disease in patients with schizophrenia (9, 10). CATIE study showed that after 10 years the risk of developing coronary heart disease is increased in patients with schizophrenia, compared with the general population (11). A study published by Jin et al in 2011 in Schizophrenia Research, using the Framingham 10-year coronary heart disease predictions (uses as predictors the age of 30-74 years, diabetes, smoking, blood pressure, total cholesterol and LDL cholesterol) suggests that middle-aged patients with psychotic symptoms have the Framingham 10 years prediction score of coronary heart disease significantly increased, especially among those with schizophrenia (12). Type 2 diabetes is increased in prevalence in individuals with major psychiatric disorders. This is probably due both to antipsychotics that cause weight gain, hyperglycaemia and dyslipidemia, as well as to the improper lifestyle, lack of exercise, inadequate diet (13). Type 2 diabetes increases the risk of cardiac disease for 2 to 4 times and it is considered to provide an equivalent risk of a coronary event as the one induced by pre-existing cerebrovascular disease. American Diabetes Association recommended statins as the first-line therapy for the treatment of hyperlipidaemia (inhibitors of 3-hydroxy-3methylglutaryl-coenzyme A (HMG-CoA) reductase), and for those with diabetes and high blood pressure or kidney disease, the same association recommends inhibitors of the angiotensin converting enzyme and angiotensin receptor antagonists. They are designed to improve cardiovascular parameters and progression of diabetic nephropathy where it exists. A study published in 2008 by Kreyenbuhl J et al (14) showed that individuals who England: London. Khasawneh F. 10.8%. Second edition. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. Torsades de pointes. A persistent hypotensive effect was associated with significant side effects. These are due to the major psychiatric disorders. 11. admitted to a psychiatric hospital for 25 years. 4. Perhaps an essential feature of these patients is the neglect of health in general. Schizophrenia Research 2005.1155/2014/273060 17. Orthostatic hypotension is due to blocking of adrenergic α1 or anticholinergic effects of antipsychotic medication. Hennekens CH. A compare study of ten-year cardiac risk estimates in schizophrenia patients from the Catie study and matched controls. 17. Schizophrenia is associated with excess multiple physical health comorbidities but low levels of recorded cardiovascular disease in primary care: crosssectional study. once more.175: 126-132. Another study published this year. in other cases the sudden death was due. Cardiology Research and Practice 2014. Jin H et al. 3. Heart disease schizophrenia and affective psychoses: epidemiology of risk in primary care. Curkendall SM. this only renders vulnerable. specific treatments recommended and are certainly much less adherent to therapeutic indications. may provide much less information about related comorbidities. haemopericardium and brain tumours (15). Minimizing cardiovascular adverse effects of atypical antipsychotic drugs in patient with schizophrenia. Haas SJ. Cardiovascular disease in patients with schizophrenia in Saskatchewan. 2015 frequently resort to mental health services have a lower likelihood of being prescribed above mentioned treatments to prevent cardiovascular risk in patients with diabetes and dyslipidemia or high blood pressure or diabetes and diabetic nephropathy (14). 7. However. inflammation of the heart muscle is a rare side effect. this special category of patients with significantly impaired quality of life.111(3): 171-6. Psychiatric care of the medically ill. Textbook of psychosomatic medicine. such as smoking or excessive alcohol consumption.125: 295-299. Smith DJ. Torsade de pointes induced by psychotropic drugs and the prevalence of its risk factors. caused by clozapine (18).9%. Coronary heart disease and cardiac conduction abnormalities in patients in persons with psychotic disorder in a general population. obstructed airways 7.198: 434-441. Newcomer JW. Suvisaari J. Kreyenbuhl J. paradoxically. Community Mental Health Journal 2005.142: 52-57. Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis. 13. in equal measure of about 2 %. which could mean a weak capacity of understanding and compliance with therapeutic recommendations. they have some more contact with health systems than the general population. Use of medications to reduce cardiovascular risk among individuals with psychotic disorders and type 2 diabetes. quality of care received is lower. 12. 2011. Antipsychotic medication causes a number of cardiovascular complications: orthostatic hypotension. Medical illness and schizophrenia.8%). arrhythmia. followed by respiratory diseases (pneumonia 11. Schizophrenia Research 2008. especially those involving lifestyle changes through proper nutrition. Canada. Schizophrenia Research 2012. Schizophrenia Research 2014. Justo D. ISBN 978-1-58562-346-4 2. Goff DC et al. side effects of psychotropic medication and inadequate living style. 15. *** 3 . REFERENCES 1. high blood pressure.1. Nasrallah HA. American Heart Journal 2005: 115-121.155: 72-76. Second edition. The cause of death was myocardial infarction 52. Medical Journal 2009. No. sought to identify the most common causes of sudden death in patients with schizophrenia. Although. 57 have died suddenly.65: 715-720. Levenson JL. Journal of Clinical Psychiatry 2004. 16. The British Journal of Psychiatry 2011. 2009. in severe cases (16). Patients with psychiatric disorders from the schizophrenia spectrum can associate a number of cardiovascular diseases during evolution. 18. Compared to the general population. a polymorphic ventricular tachycardia associated with QTc interval prolongation (17). ISBN 978-158562-379-2 6. Drug Safety 2007: 47-57. Are the cardiometabolic complications of schizophrenia still neglected? Barriers to care. The American Psychiatric Publishing. to pulmonary embolism. giving up unhealthy habits. Psychiatry Research 2010. 256-265. Mayer JM. based on autopsy reports. This may be due to the fact that experts consider a sign of "mental instability" frequent contacts of patients with psychiatric services. dilated cardiomyopathy. Newcomer JV. 5. High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia.80(1): 45-53. McDermott S. Mitchell AJ.41: 747-745. 9. Increased Framingham 10-year risk of coronary heart disease in middle-age and older patients with psychotic symptoms. BMJ Open 2013: 3. such as stroke and myocardial infarction. From a sample of 7189 patients with schizophrenia. 8. Lambert T. Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993-2003. Myocarditis.9%. Ifteni P. Schizophrenia and increased risks of cardiovascular disease. exercise. CNS Drugs 2005. Schizophrenia Research 2011. Sudden unexpected death in schizophrenia: Autopsy findings in psychiatric inpatients. myocarditis. myocarditis 5. torsade de pointes may cause sustained ventricular fibrillation and sudden death (16). Acta Psychiatr Scand 2005. Several atypical antipsychotics can cause QT interval prolongation.190(4 Suppl): S39-42. haemorrhagic cerebral accidents. doi:10. Kurdyak P.19(supp 1): 1-93. Although often resolves itself. vol.Romanian Journal of Psychiatry. 14. XVII. personality disorder. leading to personality disorders. An interesting perspective is a longitudinal one. scale developed by J. that makes the evaluation easy to perform. It follows the earlier Semi-Structured Interview for ADHD in adults. Studies of adults diagnosed as hyperactive in childhood and clinical descriptions of childhood hyperactivity persisting in adults with other psychiatric disorders where the elements that led Wender to consider the possible persistence of ADHD into adulthood . from the DSM V perspective there is a well established diagnosis of adult ADHD. Key words: Adult ADHD. Francken (2.S. based on the DSM-IV criteria. impairment in different areas and high rates of psychiatric comorbidity. Traditionally considered a disorder belonging to the child and adolescent psychiatry. Bucharest. the number of symptoms necessary for diagnosis is 5 in adults. Kooij and M. Revised December 15. Historically. and interferes with adaptive functioning” (1).6/1 adults) (1). impulsivity and hiperkinesia may interfere with functionning. clinicians use the Diagnostic Interview for ADHD in Adults (DIVA). In terms of gender it is considered the following proportion: B/F=2/1 (1. The scale evaluates the symptoms present (18 criteria ) in both chilhood and adulthood and gives examples from everyday life. ADHD is now a condition that gathers several simptoms that are recognized also in adult psychopathology. Some studies evaluate the association with other diagnoses such as anxiety. There has been a growing interest in studying the course of the disease in the adult life. dysthymia. some researchers seeing simptoms that persist from childhood to adulthood. hyperactive. in the direction of facilitating the diagnosis: the age of the symptoms' onset is 12 instead of 7. often persists throughout development. Attention-deficit/hyperactivity disorder (ADHD) is characterized by a “persistent pattern of inattentive.J. substance use disorders. DSM V suggesting 5% in children and 2. when Wender and colleagues at the University of Utah published initial findings on minimal brain dysfunction in adults. In DSM V the perspective on ADHD diagnosis has been changed. the adult ADHD diagnosis has been the subject of many controversies. To explore the adult ADHD pathology. starting from the mid-1970s. Accepted January 05. 2015 4 . To conclude. Today.5% in adults. hiperactivity. The information is taken from 1 Psychiatry MD.H. There have been made associations with temperament and character dimensions. the ADHD diagnosis became with the new classification in DSM V a new entity in adult psychiatry. the disorder being associated with poor socioeconomic outcome. ADHD symptoms in adults. nowadays a corect examination and diagnosis is a clinical examination sustained by a standardised evaluation. depression. it is estimated that 5%–8% of schoolaged children and 4% of adults in the United States suffer from some form of attention deficit disorder.SPECIAL ARTICLES ADULT ADHD – A NEW ENTITY IN PSYCHIATRY (DSM V) Laura Aelenei 1 Abstract: Subject of a series of controversies in the recent literature. 2014. capable of interacting with the developement of the individual's personality. attention deficit. Romania Received November 12. As we know. and impulsive behavior that begins early in childhood. impulsivity. 3). we can say that studying the ADHD pathology in the adult age may lead to a different perspective on some of the disfunctionalities of some of our patients that can improve the quality of their life. etc. Research in the recent literature followed several ideas. PhD Student in Psychiatry. attention deficit. After several years of debating whether or not it should be considered this diagnosis in adult psychiatry. 2014. cyclothymia. The clinical picture in mania includes euphoria. Given its history. His hypothesis is that “ADHD and autism spectrum disorders are associated with specific temperament configurations and an increased risk of personality disorders and deficits in character maturation” (18). to a closer look. irritability. and they have no proven advantage over clinical diagnosis of ADHD (8). harm avoidance (HA). that have an episodic pattern. Psychoticism) (1). Let us look closer to the area of personality disorders. increased energy. histrionic. dependent. 12). A very interesting aproach of the idea that what happens during childhood has an impact on future pathology is described by Henrik Anckarsarter in his study . Disinhibition. If we are referring to personality disorders in cluster B. There have been several lines of research in the recent literature. In DSM V the classic approach of personality disorders remained the same. mood changes. The latest data show that the persistance of ADHD simptoms in the areas of attention deficit. schizotypal. there are a few things to be observed. The research shown neurocognitive and biological differences between persons with and without ADHD. 15. personality disorders have symptoms that are relatively constant in time. The course of bipolar disorder is an episodic one. substance use disorders (9. quantitative electroencephalography. substance use disorders (9. borderline. dysthymia. There is considerable interest in development of nonclinical. even agitation. in ADHD the symptoms are somehow constant (10). There were some researchers that describe correlations between the temperament and its dimensions the way it was classically described by Cloniger and symptoms of ADHD. is pervasive and inflexible. A personality disorder is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. 3). 13). cluster B: antisocial. simptoms can be unrecognised and explained by other diagnoses such as anxiety. 6. 2015 the patient and it can be sustained by another family member. There are different researchers that used tests of executive functioning and working memory. intimacy) and pathological personality traits (Negative affectivity. evolution thought to be mediated by environmental influences (12. Detachment. distractibility. There are some elements to consider if we are thinking of an affective disorder. uselessness. This approach is somehow similar to the spectrum approach used in other disorders. vol. overactivity. Impulsivity leads to hasty actions. 11. 10. Another direction in recent literature has been the interest in the characterization of patients with early and late onset of ADHD impairment in terms of neuropsychological and personality characteristics. Antagonism. and leads to distress and impairment” (DSM V) (1). In adults hiperactivity. often associated with substance use pathology (alcohol. ADHD has been associated with poor socioeconomic outcome. Longitudinal studies show that symptoms that lead to a diagnosis of ADHD are visible at the beginning. but it has also been elaborated an alternative model for this pathology. inattentiveness. neuroimaging methods using proton magnetic resonance spectroscopy (4. interrupting others. No. laboratory tests for adult ADHD. there has been a growing interest in studying the course of the disease in the adult life. functional impairments and high rates of psychiatric comorbidity. opioids. and persistence (PS) (14. Other instruments used are Wender Utah Rating Scale. The ten specific personality disorders are grouped as we know in three clusters (cluster A: paranoid. Some have examined the association between ADHD severity and the lifetime prevalence of other psihiatric conditions in adults with ADHD. SCID-II for personality disorders 5 . or some unpleasant events such as car accidents. impulsivity and hiperkinesia in adult life may interfere with functionning. manifested by reslessness. Conners Rating Scale (2. but the accent of the patient`s complains is usually on he ideas of incapacity. insomnia. narcissistic. it was shown that in time it is frequently associated with clinical and psychological impairments. 7). Inatention leads to bad concentration. XVII.The majority of studies are limited though to small numbers of subjects.1. laboratory tests of attention. polipragmasia. Given the increasing evidence of the impact of this disease on functionality. etc) and pay attention to the sequence of symptoms and their evolution. Another issue is the financial one. Some symptoms are similar to those in ADHD. the disorder has been better studied in children. empathy. 10. Temperament describes an individual's profile of biological response patterns to external stimuli.Romanian Journal of Psychiatry. In time they may lead to the development of antisocial behavior. Latest data suggest that 1020% of the general population has a personality disorder. which is reflected in individual differences in emotional responses to the environment. amphetamines. cluster C: avoidant. 16. 11). anxiety disorders. 5. The alternative model is a dimensional one. meanwhile. Unlike affective disorders. An example is the differential diagnosis with Bipolar Disorder. bad decision making. depression. schizoid. is stable over time. in a longitudinal analysis. Another issue approached was the differential diagnosis of ADHD and he possibility of different interpretation of symptoms. obsessive-compulsive) (1). with an intensity variation of symptoms in time. Personality disorders are characterized by impairments in personality functioning (identity. has an onset in adolescence or early adulthood. irritability. antisocial and borderline PD. The independent dimensions are: novelty seeking (NS). cocaine. self-direction. such as depressive episodes. bipolar disorders. is less proeminant than in children. a reason being the fact that these methods are more objective than clinical interviews and clinical diagnostic criteria. reward dependence (RD). But. For some adults. incapacity to relax. because laboratory assessments involve significantly more expense than rating scales and clinical interviews. Even if in most of the cases the intensity of the simptomatology is weaker than in children. potentialy harmful. cyclothymia. there are some differences. somehow similar to ADHD symptoms. having the aim to better evaluate the individual in a population in which traits are continuously distributed (1). In his study he evaluated adults with specific instruments like TCI. In depressive disorders the depressive mood can be sometimes accompanied by restlessness. 17). personality disorders. disorganised work. Saint Louis. Substance Abuse Disorder in A d o l e s c e n t s . Familial Risk Analyses of Attention Deficit Hyperactivity Disorder and Substance Use Disorders.1176/appi. Wozniak J. Cortese S. Am J Psychiatry 2012. Khushmand R. doi:10. Thalamo-Cortical Activation and Connectivity During Response Preparation in Adults With Persistent and Remitted ADHD. Biederman J. Searight R.163. The conclusion was that “a patient with a childhood-onset neuropsychiatric disorder. doi: 10.1176/appi. methylphenidate) has proven its efficacy in treating ADHD symptoms in child for years.1176/appi. There are however several controversies regarding the risks and benefits of the therapy.12010087 11. Examining the Comorbidity Between Attention Deficit Hyperactivity Disorder and Bipolar I Disorder: A Meta-Analysis of Family Genetic Studies. control of voice. Radua J.58: 125-131.1176/appi.ajp. Spencer T et al.8(2): 269-275. Biederman J. adaptive decision-making strategies. doi:10. doi:10. FOCUS Spring 2010.ajp. Rottnek F et al. Am J Psychiatry 2011. Kelly C.12. The overlap between DSM-IV personality disorder categories was found to be high (18). Patients with ADHD were shown to have high novelty seeking and high harm avoidance. J ADHD Relat Disord 2010.163: 1730-1738.1176/appi. Barkley RA. Character.11. especially the persistance of symptoms in the adult life would lead to an important improvement of the quality of life of some of our patients.1593 9. Strong RE et al.12101360 17. Deficient emotional self-regulation in adults with attention-deficit/hyperactivity disorders (ADHD): the relative contributions of emotional impulsiveness and ADHD symptoms to adaptive impairments in major life activities. Monuteaux M et al. Family Medicine of Saint Louis Residency Program. doi:10. adequate perception. 2013.167: 409-417. Addressing Comorbid ADHD. posture. Biederman J.2013.163: 1720-1729.09050736 13.170: 1011-1019. Surman C. Barkley RA. Their variation may influence in his opinion personality development to a greater extent than recognized in current personality theory (18). *** . 16. doi:10. His ideas are that certain childhood temperament profiles may impair healthy character development. Diagnosing Adult Attention Deficit Hyperactivity Disorder: Are Late Onset and Subthreshold 6 Diagnoses Valid? Am J Psychiatry 2006.ajp. Petty C. Impact of Psychometrically Defined Deficits of Executive Functioning in Adults With Attention Deficit Hyperactivity Disorder. Am J Psychiatry 2008.1176/appi.62(9): 2077-2086. Hinnenthal J. Psychiatric Services 2005. 3. doi:10. Clerkin S. Medication has been used with success in adults but the experience is more limited.169: 1038-1055. Biederman J. mimicry. Murphy KR. Some of the simptoms misdiagnosed at first can benefit of specific treatment that can influence the evolution of the disease and prevent complications. might well be diagnosed as having a "primary" personality disorder when assessed in adult age” (18). doi:10. Rubia K et al. particularly if previously undiagnosed.2012. mentalizing (18). Sterling K. Association Between Variation in Neuropsychological Development and Trajectory of ADHD Severity in Early Childhood.2012.ajp. Missouri Am Fam Physician 2000. while cluster A and C disorders were more common in those with autism spectrum disorders. Fried R et al.2007. If we are to consider the therapeutic area.ajp.165: 107-115. 161.163.ajp.10. Petty C.168: 617-623.1176/appi. Barkley R.1: 5-37. 07030419 10. Stahlberg O. Burke J. we find elements to sustain the importance of the ADHD diagnosis. Biederman J. 2. Faraone S. Adult Psychiatric Outcomes of Girls With Attention Deficit Hyperactivity Disorder: 11Year Follow-Up in a Longitudinal Case-Control Study. Rindskopf D et al. 15.11020281 7.pn. interpersonal skills. d o i : 10. producing personality disorders in adulthood (18). Cluster B personality disorders were more common in subjects with ADHD. Trampush J.Laura Aelenei: Adult Adhd – A New Entity In Psychiatry (dsm V) disorders and scales for other neuropsychiatric disorders (18). 5 ed.1176/appi. doi:10. Am J Psychiatry 2013.2014. Adult ADHD: Evaluation and Treatment in Family Medicine. Marchant BK. Stimulant medication (atomoxetine. doi: 10.ajp. Reimherr FW. doi:10. The Impact of ADHD and Autism Spectrum Disorders on Temperament.ajp. Petty C. C l i n i c a l a n d R e s e a rc h N e w s 2 0 1 4 .1176/appi.2010. Chabernaud C et al. Washington. Berwid O et al. American Psychiatric Association. Gray Matter Volume Abnormalities in ADHD: Voxel-Based Meta-Analysis Exploring the Effects of Age and Stimulant Medication.2009. Am J Psychiatry 2006. J ADHD Relat Disord 2010. 12070880 6. Nakao T. Wilens T et al. Am J Psychiatry 2012.1948 14. Spencer T et al. 19. Am J Psychiatry 2010.1176/appi. Personality disorders were found to be common in followup studies of subjects with neuropsychiatric disorders.11101521 5. Am J Psychiatry 2004. As a conclusion.169: 1256-1266. 1: 5-28.170: 1205-1211. 4. Deficient Emotional SelfRegulation and Adult Attention Deficit Hyperactivity Disorder: A Family Risk Analysis. we can say that exploring the area of ADHD pathology. Diagnostic Controversies in Adult Attention Deficit Hyperactivity Disorder. Toward Systems Neuroscience of ADHD: A Meta-Analysis of 55 fMRI Studies. A Comparison of Service Use and Costs Among Adults With ADHD and Adults With Other Chronic Diseases. Keeping in mind the Cloninger's biopsychosocial theory of personality (based on the assumption that personality involves four temperament dimensions and three character dimensions). Deficient emotional self-regulation: a core component of attention-deficit/hyperactivity disorder.ajp. Emotional dysregulation in adult ADHD and response to atomoxetine. 10081172 18.161: 1948-1956. Biederman J.10. he assessed the individuals' abilities such as attention.1176/appi. Perwien A. Schulz K. Faraone S.ajp. doi:10.2011. REFERENCES 1. DC: American Psychiatric Publishing.2012. and Personality Development. Watts V.1176/appi.ajp.1720. Am J Psychiatry 2013. There is now an interest in studying the efficacy of stimulant medication in reducing the evolution of simptoms in adult life (19). impulse control. Anckarsäter H. Biol Psychiatry 2005. One of the concerns is the potential for addiction of the stimulant medication.56. McGough J.1176/appi. Am J Psychiatry 2011.ps.168: 1154-1163. Larson T et al.12a15 12. Diagnostic and Statistical Manual of Mental Disorders.1730 8. Correspondence: szaszisti2009@yahoo. Although the above mentioned model integrates the experiences of the last decades in an elegant manner. Of course this led researchers to introduce the dimensional approach which brings a lot of information about the trait profile of a person and conserves the continuum between normality and pathology. 3 MD Psychiatry resident.REVIEW ARTICLES DIAGNOSING PERSONALITY DISORDERS: A MODERN VIEW István Zs Szász1. But what is a personality disorder? We probably agree on the fact that it is a condition when nature and nurture form a personality that can't cope with the problems of everyday life and this state finally leads to suffering.com MD Psychiatry resident. University of Medicine and Pharmacy. on personality disorders and we strived to find strategies and algorithms to diagnose and treat these conditions. it cannot be considered a model that fully reflects the expected holistic approach of PD. Tudor Nireştean3. Adrian I Horvath2. pointing out the importance of moral conscience. but as we know there are a lot of overlaps between different domains. First we will present our concerns about the alternative DSM-5 model then we will describe the utility of mapping traumatizing life events and defense mechanisms. In this article we will try to analyze PD from the perspective of the alternative DSM-5 model. Received September 05. When diagnosing PD the clinician has to be aware that after the diagnosing procedure he has to establish a therapeutic plan which can consist of psychotherapy alone or in combination with the psychopharmacological treatment. Targu Mures. PhD Candidate at Psychiatry Clinic II. PhD Candidate at Psychiatry Clinic II. Targu Mures. Revised October 31. Developmental trait personality models take into account both the underlying biological dispositions to observable behaviors and individual differences in responses to experience during personality development (1). namely low scores on Selfdirectedness and Cooperativeness(2). defense mechanisms. So the alternative DSM-5 model of PD could be considered a good effort to combine the above mentioned dimensional models. like the five factor model. The differences between two persons diagnosed with borderline personality disorders can be so significant that it is impossible to find a common guideline to even try treating them. Anna M Tóth4 Abstract: The alternative DSM-5 model for personality disorders (PD) evaluates the level of personality functioning on a continuum and considers that the disturbances in self and interpersonal functioning constitute the core of personality psychopathology. 2014 2 7 . are extremely useful. A developmental personality model is Cloninger's seven factor model. that a personality disorder is a deficiency of self and interpersonal functioning. Phenotypic trait personality models. traumatizing life events. Targu Mures. moral conscience. This model defines PD as moderate or greater impairment in personality functioning and the presence of at least one pathological personality trait which can be assessed with The Personality Inventory for DSM-5(PID-5) (3). Accepted November 28. 11 MD Psychiatry resident. which needs to be mentioned because the model stated 20 years before the introduction of DSM5. Targu Mures. The above statement is adopted by different models in different ways. Key words: Personality disorders. The categorical approach seemed to bring too less information about the person and leaves no room for individualized treatment strategies. 2014. PhD Candidate at Psychiatry Clinic II. 2014. INTRODUCTION The past decades brought a lot of theories on the structure of personality organization. 4 Medical Student. defense mechanisms and life events when assessing personality and to propose an algorithm to diagnose PD in a manner that might help clinicians to establish a more individualized treatment strategy. divorce. Figure 1. somatization and Cluster C PDs use undoing and idealization. Tudor Nireştean.István Zs Szász. Any traumatizing life event can slow down or stop character development which leads to an immature character and implicitly to a PD. To map these defense mechanisms we can use Vaillant's categorization of defense mechanisms which includes 4 levels : pathological. Figure 1. If the character develops and reaches maturity the person can adopt mature defense mechanisms like humor. Cluster A PDs use projection and fantasy. Proposed classification of traumatizing life events .) 8 Problems with primary support group Death of a family member Health problems in family Disruption of family by separation. Proposed classification of traumatizing life events . or estrangement Removal from the home Problems related to the social environment/E ducation Inadequate social support Discrimination Discord with teachers or classmates Housing/ Economic problems Inadequate housing Unsafe neighborhood Inadequate finances Inadequate school environment Remarriage of parent Sexual or physical abuse Neglect of child Table 1. For example a person with PD rarely knows or admits that he is seen as irresponsible by others with think that questions shut be much more indirect in some cases. a mature character is not an insurance for a life: cranio-cerebral traumatisms and substance abuse can also affect character and accelerate the physiological decline resulting in an organic PD. which can be considered a pathological defense mechanism. Mature defense mechanisms are not shown in the table. slander. they include patience. explains these views. acceptance. d e c e i t f u l n e s s . Traumatizing events in early life It is well known that our character's maturity depends on environmental factors that occur during childhood and this is also the period of acquiring mature defense mechanisms. anticipation and a lot more. Adrian I Horvath. The development of character and defense mechanisms. these traits belong to the moral consciousness and therefore should be integrated as part of the interpersonal functioning or separately because it can be a target for psychotherapeutic interventions. g r a n d i o s i t y. immature. Pathological Delusional projection Conversion Denial Distortion Splitting Extreme projection Superiority complex Inferiority complex Immature Acting out Neurotic Displacement Fantasy Wishful thinking Idealization Passive aggression Projection Dissociation Hypochondriasis Intellectualization Isolation Rationalization Projective identification Somatization Reaction formation Regression Repression Undoing Withdrawal Upward and downward social comparisons Table 2. c a l l o u s n e s s a n d irresponsibility. humility. We think that in a holistic approach it is extremely important to obtain informations about traumatizing events in early life and defense mechanisms. calumniate or defame someone to satisfy ones sadic pleasures (4). Of course there is an informant form for PID-5. This facet could be describes as follows: directly and deliberately disparage. A primitive defense mechanism classified as pathological defense mechanism is splitting which is typical for borderline PD. altruism or sublimation. However. One of our previous studies showed that from a psychopharmacological point of view traits which are allocated to self-esteem and individual superego seem to be difficult to integrate. At the age of 3 character begins to develop and reaches a level that can “control” temperament at age of 18. Cluster B PDs can use acting out. If assessed separately moral consciousness should contain another facet called moral torture. Anna M Tóth: Diagnosing Personality Disorders:A Modern View Our first concern about this model is that it tries to obtain informations about the person who is egosintonic with his functioning and traits. The development of mature defense mechanisms has a similar path When mapping the traumatizing events in early life we could use an adopted version of DSM-IV Axis IV (5) (Table 1. Around age 35 character reaches maturity and starts its physiological decline around the age of 60. Defense mechanisms In the pathology of personality it is important to map the defense mechanisms because it can have a crucial influence on the treatment strategy we want to adopt. Unfortunately in PD the character does not reach maturity which automatically involves pathological defense mechanisms. but unfortunately we hardly get them filled out in clinical settings. denial. neurotic and mature defense mechanisms (6). namely manipulativeness. Except grandiosity. text rev. Iasi: Editura Polirom. TCI-Temperament and character inventory. 2. Figure 2. Louis. Washington. Proposed algorithm to diagnose personality disorders. XVII.R. 5. Tulburările de personalitate.Cloninger C.1. New York: Lippincott Williams and Wilkins. SD-self-direction. 2000. No.Sadock B.The Structured Clinical Interview for DSM-IV Axis II Personality Disorders REFERENCES 1.Lăzărescu M. DC: Author.). COCooperativeness. MO: Center for Psychobiology of Personality: Washington University. SCID-II.P. DSM . Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Nireştean A.Diagnostic and statistical manual of mental disorders . The temperament and character inventory (TCI): A guide to its development and use. St. 2015 Our proposed algorithm to diagnose PDs starts with the clinical diagnosis that includes also the mapping of traumatizing life events.fifth edition. 9th Edition. 1994.. 2007. 2009.American Psychiatric Association. Washington DC: American Psychiatric Publishing. PF-personality functioning. vol.Romanian Journal of Psychiatry. A. Sadock V. defense mechanisms and facets of moral conscience followed by the PID-5 without assessing the domain of Antagonism as shown in figure 2.APA.J. Ruiz P.A. 2013. Diagnostic and statistical manual of mental disorders (4th ed. 4. *** 9 . 3. Animal assisted therapies that included pets (cats. and social functioning. horses and dolphins were conducted in medical and non medical facilities (prisons. AAT is directed and/or delivered by a health/service professional with specialized expertise and within the scope of his/her profession. Animal assisted activities (AAA) are defined by the same organization. in association with animals that meet specific criteria (1). University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca Received June 27. educational. These were believed to be effective tools for socialization. greatly influencing the morale of the patients living there (5). Veronica Şut4. Wilson's. 2014 10 . Delta Society. A therapist who brings along a pet may be viewed as being less threatening. Alina S Rusu2. if we see animals at rest or in a peaceful state. Assistance dogs can also assist people with many different disabilities. increasing the rapport between patient and therapist (2). 400012. they are capable of assisting certain life activities and help the individuals navigate outside of the home (6).REVIEW ARTICLES ANIMAL ASSISTED THERAPY. Department of Special Education. 8. Key features include: specific goals and objectives for each individual and measure progress. psychiatry clinics. Accepted August 29. this may signal to us safety. Proven benefits are of physiological and psychological nature. the Bethlem Hospital in England followed the same trend and added animals to the ward. led by William Tuke (4). nursing homes. emotional. or cognitive functioning. and even reduced cardiovascular morbidity and mortality (7). In 1860. 1984 (3) biophilia hypothesis is based on the premise that our attachment and interest in animals stems from the strong possibility that human survival was partly dependent on signals from animals in the environment indicating safety or threat. INTRODUCTION Animal assisted therapy (AAT) involves an interaction between patients and a certified trained animal. The earliest reported use of AAT for the mentally ill took place in the late 18th century at the York Retreat in England. 2014. depression. Phone:+40745-502-649. dogs). The documented benefits of AAT include improved physical. Psychiatry Department. Ioana V Micluţia6 Abstract: A substantial amount of recent research highlighted the health benefits of human-animal interactions. Babes-Bolyai University. Victor Babeș Street no. Patients at this facility were allowed to wander the grounds which contained a population of small domestic animals. Physiological benefits include improvement in blood pressure and heart rate. Anca Zăgrian3. Cluj Napoca 3 Psychologist''Dog Assist” Association 4 Psychologist. mental institutions and hospitals. anxiety and cognitive functions are the most important symptoms that may benefit for animal assisted therapy. pain management clinics. which purpose is to facilitate the patients' progress toward a therapeutic goal. Romania. pediatric clinics. anxiety. (3). Revised July 31. Animals can be used in a variety of settings such as prisons. George Moşoia5. recreational and/or therapeutic benefits to enhance quality of life. The biophilia hypothesis suggests that now. as activities that provide opportunities for motivational.com 2 Associate Professor. reduced blood pressure and triglyceride levels. etc. Romania. emotional.BENEFITS FOR PATIENTS Ramona L Păunescu1. Key words: animal-assisted therapy. '' Dog Assist” Association 5 President '' Dog Assist” Association 6 Professor Doctor. 2014. Faculty of Psychology and Sciences of Education. Head of Psychiatry Department. Correspondence:Ramona Păunescu. Depression. The goal of AAT is to improve a patient's social. In the last decades AAT has received a growing interest and it has been used in several medical areas. There are studied involving canine assisted therapy conducted in cardiology departments. E-mail: ramonaboia@yahoo. one of the most important organizations involved in the certification of therapy animals in USA defined animal assisted therapy as a goal directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. veteran's shelters. security and feelings of well-being which in turn may trigger a state where personal change and healing are possible. 1 Assistant Professor. University of Medicine and Pharmacy "Iuliu Hațieganu" Cluj-Napoca. emergency rooms. etc). AAA are delivered in a variety of environments by specially trained professionals and/or volunteers. cognitive. Cluj Napoca. and depression in psychiatric patients before electroconvulsive therapy (ECT). 34 family/friends. Braker et al (5) conducted a study that included 230 patients with different psychiatric disorders. Dog assisted therapy's potential benefits were also assessed in several pain management clinics.1. and after the therapeutic recreation session for patients with mood disorders (5).and post treatment crossover study design was used to compare the effects of a single animal-assisted therapy session with those of a single regularly scheduled therapeutic recreation session. fatigue. Pain relief interventions using AAT were made in several pediatric centers. and anxiety in patients hospitalized with heart failure. In patients who survived myocardial infarction. Visual analogue scales were used to measure anxiety. In a patient with heart failure. with systolic pulmonary artery and pulmonary capillary wedge pressure reductions after AAT (5). 9. and depression before and after treatment and standard conditions. and emotional distress were recorded using 11-point numeric rating scales before and after the therapy dog visit or waiting room time. The results provided strong evidence that AAT can reduce pain in children up to four times more than for the children who did not interacted with animals. The pain reduction felt by the children after 15 minutes of interaction with a dog was comparable with the use of oral acetaminophen with and without codeine in adults (22). heart rate. consisting of a 15-minute AAT session. and other disorders. Thus. A pre. The review of Wolff et al (20) highlighted the positive effects of human-animal interaction on the cardiovascular system and on the improved survival after a myocardial infarct for pet owners. whereas the third group received a visit form a trained therapy dog. In another study. XVII. a self-report measure of anxiety currently felt. heart rate. and mortality 1 year after the infarction was lower in those who were pet owners than in those who were not (12. ANIMAL ASSISTED THERAPY IN MEDICAL FIELDS Animal assisted therapy has already proven its efficacy as reported by clinical studies. The physiological variables (blood pressure. Participants were able to spend the waiting time in the clinic with a certified therapy dog instead of waiting in the outpatient waiting area. Sobo et al (23) included 25 children aged 5 to 18 who underwent surgery and experienced post operative pain. Other medical fields were dog assisted therapy was successfully used were emergency departments (24) and military medicine (25). referred for therapeutic recreation sessions. ANIMAL ASSISTED THERAPY IN PSYCHIATRY Anxiety disorders and anxiety symptoms were among the first psychiatric fields where animal assisted therapy was used. 2015 Psychiatric patients benefit by reduced stress. In the Cardiac Arrhythmia Suppression Trial. Patients with heart failure have lower epinephrine and norepinephrine levels. These data support the hypothesis that excess activity of the sympathetic nervous system due to both physiological and psychological stress can be reduced by AAT. 10). mood disorders. In the study. the risk for cardiovascular disease. in the second group the patients were asked to relax quietly in the bed. 13). and the standard (comparison) condition. speech) than did patients who were not pet owners. For all groups relaxation interventions lasted 12 minutes. Therapy dog visits were also able to improve emotional distress and feelings of well-being in family and friends accompanying patients to appointments and clinic staff (21). The study findings suggested that dog assisted therapy may be useful as an adjuvant to the traditional pain treatment for children (23). 18). The results highlighted the fact that animal-assisted therapy may have a useful role in 11 . 35 patients were assigned on alternate days to the treatment condition. The aim of the study was to determine whether the interaction between patients and therapy dogs improves hemodynamic measures. consisting of 15 minutes with magazines. The same author. Results showed that therapy dog visits in an outpatient setting provided significant reduction in pain and emotional distress for chronic pain patients. The patients were divided into two groups: the first one (n=18) received AAT. and plasma rennin activity in response to mental stressors (mathematical subtraction. Braun et al (22) investigated the change in pain and vital signs in an acute care pediatric center for children aged 3-17. (11) patients who were pet owners with long-term animal exposure had lower blood pressure. Patients with advanced heart failure are threatened by many physiological and psychological stressors (14. Results showed that animal-assisted therapy improves cardiopulmonary pressures. The results revealed a statistically significant reduction in anxiety scores after the animal-assisted therapy session for patients with psychotic disorders. SVR. fear. the presence of a nonthreatening stimulus such as a dog could relax the patient by lowering the patient's state of arousal and reduce neurohormonal activation caused by over activity of the sympathetic nervous system (17. most likely triggered by excitation of the sympathetic nervous system (16). Participants were offered one time visit form a therapy certified dog. vol. The patients were divided into three groups: the first group received the visit of a volunteer. epinephrine level. lowers neurohormone levels. A recent study conduced by Cole et al (19) assessed 76 patients with a diagnosis of advanced heart failure. Physiological stressors include the activation of the neuroendocrine cascade. subjects completed the state scale of the State-Trait Anxiety Inventory. dog ownership was a significant independent predictor of survival in patients 1 year after acute myocardial infarction. A study conducted by Marcus et al (21) included two hundred ninety-five therapy dog visits (235 with patients. anxiety. It also emphases the importance for further research in order to the complex elucidate physiological mechanism underlying these benefits. in a 2003 study tried to determine weather animalassisted therapy (AAT) is associated with reductions in fear. Self-reported pain. and 26 clinic staff). and norepinephrine level) were assessed 3 times for all groups. cardiac index. Before and after participating in the two types of sessions. and decreases state anxiety. morbidity. while the second one (n=39) did not. neurohormone levels.Romanian Journal of Psychiatry. In one study. No. several studies conducted in cardiology departments showed a decrease in blood pressure and heart rate for the participants after the interaction with trained animals and an increase in peripheral skin temperature (8. 15). During the control session the patients were assigned to a 30 minutes walk with the same research assistant. social support. Therefore. Only one of the study included in the review found a significant result (p<0. The STAI state score was significantly reduced after the presence of a dog. Results reported increased playfulness. For BPSD the studies included reported a decrease in irritability and anxiety items on the specific assessment instruments. The design of the study was meant to test several hypotheses: if the effects of AAT can decrease agitated behavior in tested patients. Compared with the control group.5) for spatial orientation. Another good example for animal assisted therapy is seen in children with autism spectrum disorder (ASD). a stuffed dog or a ball. The aspects followed were apathy. STAI was completed again after the therapy. and psychiatric symptoms was completed the week before and the week after the animal-assisted activity. The sessions were held for 15 weeks. In one study children were submitted to a 15 minutes therapy session with a dog. if agitated behavior would suffer an increase after testing until follow up. control over activities of daily living. Thirty participants were randomly assigned to either the treatment or control group. The results outlined that the group of children who participated to animal assisted interventions showed an increased attendance. the treatment group showed significant improvement on all measures except for social support and negative psychiatric symptoms. Pediatric psychiatry is also a domain where AAT has demonstrated its benefits. and other psycho-physiological aspects among inpatients with schizophrenia. The reduction of anxiety may be explained by evident changes in stress responsive biological parameters like cortisol and dopamine levels. Veronica Şut. irritability. previous documented agitated comportment. depressive symptoms and daily living activities. an improvement was reported but it had no statistical significance. The study of Chu et al (30) aimed of to evaluate the effects of animal-assisted activity on self-esteem. The study of Motomura et al (32) assessed a small sample of patients with dementia (Alzheimer and vascular dementia) while undergoing therapy with certified trained dogs. As far as the medication is concern. the study of Richeson (31) focused on animal assisted therapy on agitated behaviors and social interventions for patients diagnosed with dementia. Alina S Rusu. The review highlighted the effect of AAI on behavioral and psychological symptoms of dementia (BPSD). In another study with twelve acutely depressed patients. cooperation and engagement in learning activities. Results of the pilot study reported a decrease in agitation and a significant improvement of social interactions for the participants. 50 children were randomly assigned to an education program involving either interactions with animals or outdoor activities. a brief. The psychotherapeutically approach consisted of a 30 minutes interaction with a dog and research assistant.Benefits For Patients psychiatric and medical therapies in which the therapeutic procedure is inherently fear-inducing or has a negative societal perception (26). Each patient had to complete PANSS and the Spielberger State-Trait Anxiety Inventory before the canine sessions. the authors measured state anxiety with the State-Trait Anxiety Inventory (STAI). the study showed no need of decreased medication for the participants during AAT (31). For cognitive functions assessed with Mini Mental State Examination or Multidimensional Observation Scale for Elderly Subjects. This finding suggests that animal-assisted therapy causes highly significant reductions of state anxiety. past interest in animals and no allergies to dogs or dislike of the animals. Thus. easy-to-administer self-report measure that is widely used in research and clinical practice. focus and social awareness in the presence of the dog. its results indicated an increased sensory and social motivation and decreased inattention (35). even from the firs week of AAT. George Moşoia. The results of this study showed that animal-assisted activity can promote significant improvements in many clinical aspects among inpatients with schizophrenia.Ramona L Păunescu. Results of the study showed reduced anxiety in acute schizophrenic patients as demonstrated by a significant decrease in STAI scores after the dog assisted session (28). as well as a decreased in antisocial and violent behavior (34). Presence of dogs may offer an additional therapeutic benefit that might decrease anxiety and enhance psychotherapeutic strategies and motivation of patients and therapists (27). Both sessions took place in the same quiet room at approximately the same hour and the interval between the two sessions was one day. animal-assisted activity should be integrated into the treatment of institutionalized patients with schizophrenia (30). Another psychiatric domain where animal assisted therapy was applied is represented by the pathology of elderly. Anca Zăgrian. self-determination. Katcher et al (34) examined the effect of animal assisted therapy for children diagnosed with attention deficit hyperactivity disorder (ADHD) and conduct disorders. . as observed after a 15 minutes interaction between certified therapeutically dogs and volunteers (29). Ioana V Micluţia: Animal Assisted Therapy. The recent review conducted by Barnabei et al (33) in 2012 included a number of 18 articles from literature with themes that concentrated upon the relationship between animal assisted interventions (AAI) and dementia patients. The most significant change after AAT was found on items for apathy scale. if patients undergoing AAT would increase their social 12 interactions and if AAT could decrease the need for medication. The study participants had to meet several including criteria among witch an established diagnosis of dementia with a MMSE score <15. The second study included horses and therapeutic horseback ridings for children with ASD for 12 weeks. concentration and abstract thinking (33). Two half hour sessions were conducted with each patient. A questionnaire assessing selfesteem. cognitive functions and depressive symptoms for patients diagnosed with dementia. The fact that there was not a relationship between the cognitive level and the degree of agitated behavior suggested that AAT may be an appropriate intervention for moderate to severe cases of dementia. Several studies made upon patients with dementia were published during the last decade. The review of O'Haire (35) discussed the results of two recent studies that included this pathology. blood pressure and heart rate. Depressive symptoms and emotional liability evaluated with Geriatric Depression Scale were improved after animal-human interactions. A weekly animal-assisted activity program was arranged for patients in the treatment group for 2 months. The recent study of Lang et al (28) included 14 acute schizophrenic patients. Am J Cardiol 1995. 27. Psychiatr Serv 1998. Cole 19. Meintjes RA. Constantin JM et al. 153-177. Effect of psychosocial factors on physiologic outcomes in patients with heart failure.49(6): 797–801. fear. 24.Allen K.Nahm N . *** 13 . Handbook of Animal Assisted -therapy: Theoretical Foundations and Guidelines for Practice. J Nerv Ment Dis 1987.Braun C. In: Fine AH (ed). Springfield. Eng B.Barker SB. ISBN 0-399-12775-5 3. reduced agitation. Izzo JL Jr.Marcus DA. Dawson KS.18: 353.Wolff AI. The effect of animal-assisted activity on inpatients with schizophrenia.Katcher AH.38(4): 815–820. In: Fogle B (ed). Thomas SA.Beck A. Stein PK. Therapy Dogs in the Emergency Department. Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia.O'Haire M. US Army Med Dep J 2012: 38-45. Lin J. In: Marvin B. Best AM. Semin Integr Med 2005. Tomaka J. Steers N.15: 105-109. Perrone-Filardi P. 14. Wertenauer F et al.13(4): 363–365. J Pers Soc Psychol 1991.Friedmann E. Eur J Integr Med 2010. but not ACE inhibitor therapy. 34.16 (6): 575-585 20. 21.76(17): 1213–1217.4(2): 40-42.Serpell J.Wisdom JP.Allen K. Kleiger RE. The centaur's lessons: therapeutic educations through care of animals and nature study.Richeson NE. Am J Crit Care 2007. New York: Putnam. 2015 CONCLUSIONS Animal assisted therapy has several benefits both in medical and psychiatric fields.2: 123-127.Hoffman AOM. Dog-assisted intervention significantly reduces anxiety in hospitalized patients with major depression. Psychogeriatrics 2004. XVII. Human-animal interactions as a therapeutic intervention. Gawlinski A. Animal assisted therapy for people with dementia.19(1): 38-44. Animal assisted therapy as a pain relief intervention for children. 23. Companion animals and human health: Benefits.1(3): 145–148.24: 51-57. Kotlerman J. Thomas SA.Motomura N.14: 106–115. J Psychiatr Res 2013. Handbook on Animal-Assisted Therapy: Theoretical Foundations and Guidelines for Practice 2000. vol. Pandurangi AK. Neurophysiological correlates of affiliative behavior between humans and dogs. J ECT 2003. Gonzales F Jr. Animal-assisted therapy in cardiovascular disease. De Ronchi D. 15. Saedi GA. Physiological responses of college students to a pet. Pettingell S. IL: Charles C Thomas Publisher.Sobo EJ.Lefebvre SL. Gola GC. Eur J Integr Med 2009. J Cardiovasc Nurs 2000. Journal of Veterinary Behavior: Clinical Applications and Research 2010. Animal Companions and Human Well-Being: An Historical Exploration of the Value of Human-Animal Relationships.htm 2. The Effects of Animal-Assisted Therapy on Anxiety Ratings of Hospitalized Psychiatric Patients. social support.deltasociety.2: 131-134. 6. Animal-assisted interventions for elderly patients affected by dementia or psychiatric disorders: a review. 11. Pets and the Family. Ohyama H.14: 1–23. J Psychosoc Nurs Ment Health Serv 2009.Wilson CC.61: 582–589 9.org/aboutaat. Miner Electrolyte Metab 1999. Thomas SA.165: 296-301. Jansen BJ. challenges. 28. J Nerv Ment Dis 1983. Kassity-Krich N.175: 606–612. 1983. Reduced anxiety during dog assissted interviews in acute schizophrenic patients. West J Emerg Med 2012.Moser DK. Presence of human friends and pet dogs as moderators of autonomic responses to stress in women. and the road ahead. improved mood and increased social skills. 32. The interactions between patients and trained animals resulted in lower levels of anxiety. 30. Stangler T. Am J Infect Control 2008. Messent PR. Kim SD.36: 78–85. Journal of holistic nursing 2006.Beck CE. Worster PL. Relation between pet ownership and heart rate variability in patients with healed myocardial infarcts. Sussman M (eds). Lynch JJ. Liu CY.Lang UE. About animal assisted activity and animal assisted therapy. Vet J 2003. Lee AH. The effects of animal-assisted therapy on wounded warriors in an Occupational Therapy Life Skills program. Pet ownership.34(5): 1-18. No. KM. 26.Chu CI. Guidelines for animalassisted interventions in health care facilities. Canine visitation (pet) therapy. Hypertension 2001. Cellular events linked to cardiac remodeling in heart failure: targets for pharmacologic intervention. 8. Green CA. Yagi T.13(1): 45-57. Animal-assisted therapy at an outpatient pain management clinic. 3–17. increased cognitive performances (attention). Frishman WH. Sells CH et al.47(12): 42-8.5(5): 226-234.25(1–2): 6–10.Piano MR. 1981. NY: Haworth Press. 13. blunts home blood pressure responses to mental stress. Am J Orthopsychiatry 2009. Sun CT. 22. Interrelationships Between People and Pets. Between Pets and People: the Importance of Animal Companionship. J Cardiovasc Nurs 2000. Online Available:http://www. Bankwitz KB et al.Friedmann E. Blascovich J. 41–67. 191–203. 17. 12. Wilkins GG. Pathophysiology of heart failure.47(6): 762-73. and oneyear survival after acute myocardial infarction in the Cardiac Arrhythmia Suppression Trial (CAST). Bernstein CD. Thomas SA.Barker SB.Chiariello M.91(6): 718–721. Shykoff BE. 25. 33. 10.Friedmann E. 35.Romanian Journal of Psychiatry. Lubin J. Jarvis C. Kelsey R.79: 430–436.Odendaal JS. Health benefits of pets for families. REFERENCES 1.Delta Society. Christensen E et al. Narveson J. San Diego: Academic Press CA. New York. Retrieved 2012-03-18. 16. Wertenauer F et al. Am J Cardiol 2003. 5. 29. Katcher AH. Counseling and Human Development 2002. Am J Alzheimers Dis Other Dem 2003. 1985. and depression before ECT. Social interaction and blood pressure: influence of animal companions. Pet ownership. Effects of animal-assisted therapy on patients' anxiety. Pilot data on decreases in child pain intervention.Schaefer K. 18.1. Another breed of “service” animals: STARS study findings about pet ownership and recovery from serious mental illness. 31. 7. Complementary therapies in clinical practice 2009.Katcher AH. Pain Med 2012.171(8): 461–464. La Ferla T et al. Animal-Assisted Therapy in Patients Hospitalized With Heart Failure.Friedmann E. Interactions between people and their pets: form and function.Bernabei V. 4. poor involvement in occupational therapy. Further studies are needed given the methodology limits of this study. CGIS (p=0. most often for cluster B. schizophrenia. Romania 4 MD. Key words: forensic psychiatry. PhD.Legal Service. PhD. Patients. Conclusions: Personality disorder.9%) followed by borderline PD and mixed PD.000.045) and on occurrence of violence (Kaplan-Meier analysis: Log Rank=16. Buzău County Received August 18. 27 female) were diagnosed with PD.ORIGINAL ARTICLES PERSONALITY DISORDERS AND PSYCHOTIC DISORDERS – CO-MORBIDITY IN FORENSIC INPATIENTS Monica D Moșescu1. is a quite common comorbid with psychotic disorder in this forensic sample and is independently associated with an increased risk of violent behaviour in psychosis. Results: 50. Romania. Unguriu. Head of Department. PANSS-EC (p=0.177. This observation is important for risk assessment and risk management in forensic inpatients. Buzau County. hospitalized in the forensic wards were screened for personality disorder. Statistical analysis was performed with SPSS 17. CGI-S and HCR-20 at baseline. use of mood stabilizers. Gabriela Costea 4 Abstract: Background: Comorbid personality disorder and psychotic disorders always represent a major challenge for every day practice. Participants were assessed using PANSS. md_mosescu@yahoo. Accepted October 27.032). The final sample was divided in 2 groups: with PD and without PD. 2014 14 . Buzau. Most common was antisocial PD (36. Psychiatry and for Safety Measures Hospital Sapoca. personality. We observed significant correlations (p<0. 1 MD. Forensic Psychiatry Department. diagnosed with schizophrenia or other psychotic disorders. Romania * SPMS Sapoca – forensic psychiatric wards Ojasca.0.7% from the final sample of 128 patients (101 male. participation in occupational therapy. 2014.007).05) between PD and alcohol use. There were no significant correlations between the types of PD and the variables followed. phone: 0238528146 fax: 0238528474. Buzau. The aim of this study is to analyze the implications of dual diagnosis of psychotic disorder and personality disorder among forensic inpatients. Psychiatry and for Safety Measures Hospital Sapoca. Address: SPMS Sapoca. PhD. There were differences between groups on clinical improvement (mixed ANOVA): PANSS-T (p=0. Alina V Ungureanu2. 2014. antipsychotic combination therapy. p =. Medical . The Mann-Whitney test confirms correlations obtained from cross-tabulations. 127540. Method: It's a non-interventional study performed in Săpoca Forensic Psychiatry Hospital during 12 months. Bucuresti. The design was approved by the Ethical Board of SFPH. We used information only from medical files. after 6 months and at the endpoint (12 months. Magdalena Dragu3. We followed treatment received. Revised September 30. 2 MD. National Medico-Legal Institute. occurrence of violence.com. and occurrence of violence during follow-up period. Buzau. Romania 3 MD. 109 subjects completed the study (53 with PD and 56 without PD).Scale of positive and negative symptoms in schizophrenia).component score) and CGI-S (8. There were excluded patients with length of stay longer than 2 years. excited. R and total) and violence risk assessed (low. 9). The final risk assessment of violence was made following the discussions of the two independent assessors with accredited training (10). There is few data in literature relating to those with schizophrenia (or other schizophrenia spectrum disorder) also diagnosed with personality disorder who committed a criminal act (more often violent) and are referred to forensic psychiatric services (compulsory hospitalization as medical safety measures according Romanian law). C. as well as with poor response to psychosocial rehabilitation and crime reduction programs (2). Instruments Psychotic disorder was diagnosed accordingly to ICD-10 (6) and PD was assessed with semi-structured interview SCID-II (7) only from a categorical perspective and not dimensional and the diagnosis was based on ICD10 (F60-F61).OT) and the interpersonal violent behaviour. and more broadly. No. vol. MannWhitney test. With respect to prognosis. Statistical analysis of data was performed with SPSS 21. gender. There were included in the study patients hospitalized in forensic psychiatric wards diagnosed with schizophrenia or other schizophrenia spectrum disorder: F20-F29 according to ICD 10 (International Classification and Statistics of Diseases and Related Health Problems. CGI-S. Methodology of the study and informed consent model were approved by Ethical Board of Sapoca PSMH. and HCR-20. medium and high). general and total scores. non-interventional one. The tests used were chosen based on the type of variables: t test for two independent samples (interval variables). At baseline assessment there were identified 65 subjects with PD and 63 without PD. The patients were evaluated at baseline. CGI-S (Clinical Global Impression . mixed). the number of forensic psychiatric inpatients has been growing markedly and risk assessment and management of patients with severe mental illness are increasing priorities for mental health services (5). On the other hand. aged 18-65 years who have signed consent for participation. PD may be associated with increased risk for criminal and violent behaviour. and occupational therapy . RESULTS Participants At screening the group of 128 subjects were diagnosed with schizophrenia or other schizophrenia spectrum disorder and 28 of them had a diagnosis of PD.1.Clinical Global Impression -severity) and HCR-20 (Historical Clinical and Risk Management). correlational analysis. at 6 months and 12 months (end of study): PANSS. offense. The study was conducted on a vulnerable population. withdrawal of consent. to society. MATERIAL AND METHOD Participants. the reasons for non-completion (19 cases) were different (medical. Patients were evaluated and have been applied scales: SCID-II (Structured Clinical Interview for Personality Disorders Clinical). Revision 10). education. XVII. data used were collected only from medical and forensic records and the three assessments of the study corresponded to periodic assessments of forensic inpatients according to the law. psychiatric. alcohol use. The primary objective of this study is to analyze the implications of PD co-morbid with schizophrenia (or other schizophrenia spectrum disorder) on the clinical course and treatment received and on violent behaviour in patients admitted to implement safety measures of a medical nature. and occupation). Ethical Considerations The study was non-interventional. Methodological limitations There are considered as methodological limitations: the small number of participants and the lack of validation on Romanian population of assessment tools used. The secondary objective is to provide epidemiological data essential for the development of forensic mental health services strategy. PANSS (Positive and Negative Symptom Scale . The HCR-20 was used only for research purposes and the proposal to change the safety measure by the forensic psychiatric commission being based on the current methodology (mainly clinical judgment). negative. (Statistical Package for Social Sciences) for Windows. Throughout the study it was considered legal and privacy rights of the volunteer participants. To evaluate the clinical course we used PANSS (positive. scores (subscales: H. origin. ANOVA test (repeated measures. Evaluation of violent behaviour and participation in occupational therapy (OT) based on the information noted in the observation sheets by untrained medical personnel specifically for the study. mood stabilizers. Violence in hospital was considered only if it had been documented by medical staff and it was understood as damaging to one or more persons that an attempt or threat as described by the authors of the HCR-20 (10). During the study period we followed the therapeutic plan (antipsychotics.Romanian Journal of Psychiatry. unauthorized leaving hospital) (Table no. Unfortunately. 15 . The therapeutic program was conducted by the treating psychiatrist in the patient's best interest. these conditions are also widely misunderstood and misdiagnosed (1).0. accomplished by Sapoca PSMH (Psychiatry and Safety Measures Hospital) during 12 months in 2008-2009. Information used was: socio-demographic data (age. debilitating psychiatric conditions that have enormous costs to patients and their family members.1). The baseline data were obtained from medical and legal documents. forensic and criminal history. chisquare test of association – cross-tabulation (for nominal and ordinal variables). 2015 INTRODUCTION Personality disorders (PDs) are common. More than half of those with PD also had an axis 1 disorder (3) and patients with co-morbid psychotic disorders and personality disorders are among the heaviest users of psychiatric services (4) and forensic services also. To assess the risk of violence it was used HCR20. legal. Procedure The study is a longitudinal and observational. Kaplan-Meyer survival analysis. 116).81. PD significantly correlated with the risk of violence assessed at baseline: χ2 (2) = 7. A pie-chart illustrating the distribution of PD clusters at baseline Comparative presentation of lots (PD vs. screening We observe dominant PDs from the B cluster (antisocial. length of stay) and chi-square test (sex.50 (12. the relationship between the two variables is strong (according to Cohen. Type of PD's . p = 0.baseline vs. marital status. for criminal records (0. dependent. borderline. CGI.2%) 52 11 43. p = . 28 Table 2. phi coefficient = 0. no PD) The two samples were analyzed by independent t-test (age. p = 0. schizotypal) represents 9. 34) but the difference is not statistically significant (p = 0. scores. From the descriptive analysis it was observed that patients with antisocial PD often had a criminal history and those with borderline PD paticipated less at occupational therapy.5 times higher in PD group than no PD group (95% CI. psychiatric. Groups are similar in terms of psychopathology and clinical symptoms.Monica D Moșescu. 15) also without statistical significance (p = 0.59 (10. HCR-20). Subjects with PD were younger than those 16 PD significantly associated with criminal records: χ2 (1) = 28. area of ​origin. the mean age was lower in the PD group with statistical significance: t (104. Gabriela Costea: Personality Disorders And Psychotic Disorders – Co-morbidity In Forensic Inpatients No.611. schizoid.05).34 (8.7%) 49 16 31. p = 0. Group and subgroups: distribution on sex and mean age At baseline the most commonly diagnosed was antisocial PD (36. 2).228.20 (7.148) Endpoint 56(51. Sex male female Mean age (SD) Total Baseline 128 101 27 38. that there were no significant differences (p>0.001).000.003.595) PD Baseline 65 (50.000. PD is not significantly statistically associated with: gender. marital status.000. forensic and criminal history.358). likehood of alcohol use (OR) is 12.7. education.4%) 45 11 44.646.750) Endpoint 53(48. p = 0. education and psychiatric history (p>0. rural origin.371. p = 0. PD type mattered.542.64.2).000) and for participation in occupational therapy (-0.86 (12. avoidant) only 3% (Figure 1). occupation.7) = .047) and for repeated violence (0. narcissistic . The relationship between PD and alcohol use for final sample cluster C 3% cluster B 65% Figure 1.447. PD is associated with alcohol consumption: χ2 (1) = 37. alcohol use.2-30. 1988). PD clusters at baseline cluster A 9% mixed PD 23% Figure 2. occupation. p = 0.59) Table 1.6%) while the PDs from A cluster (paranoid. PD Antisocial PD Borderline PD Mixed PD Narcissistic PD Paranoid PD Schizoid PD Anankastic PD Baseline 24 15 15 3 4 2 2 Total Screening 16 4 8 0 0 0 0 65 without PD. Repeated violence during the study was more common . violence risk).269) Endpoint 109 86 23 38.000 and forensic history: χ2 (1) = 38.763.2) (Figure no. noting important differences towards screening (diagnosis established by initial forensic expertise) (Table no. Alina V Ungureanu.02. Murder is more common in the group without PD (21 vs. with statistically significance (Kendall tau_b correlation).16 (10. Magdalena Dragu.05) for all the scales and subscales scores obtained (PANSS.2% and C cluster (anankastic. 5.6%) 41 12 32.00) No PD Baseline 63 (49. p = 0. In the group with PD violent index offenses are more common than in the group without PD (45 vs.9%) followed by borderline PD and mixed PD. 484 5. Squares Intercept PANSS_P 130390.752 -0.000 .45 1.08 104.94 P 0. no PD) on psihopathology and violence risk test 17 .63 5.003 .002 . 4 (Tests of Between-Subjects Effects) show that the main effect of PD is statistically significant for all scores.73 107 p .231 1 155.948 1 529.7 P 0.2 0.2 125. for all scores.025 PANSS_EC 71.000 PANSS_P 529.005 Table 3.3 4.15 107 4.58 6.000 0.133 .56 125.147 .000 .124 1 28985.4 3. except PANSS_N (negative) and PANSS_G (general).124 1826. 3).677 3474. this means the improvement is significantly better in the group without TP (Table no.681 0.000 0.197 .884 21.504 4.92 122 2.497 0.504 1 71. at 6 months and 12 months also.78 96.578 0.979 2299.78 106.1. No.9 3.41 1.33 0. At the independent t test was significant difference (p <0. Clinical improvement is significant for the first six months of the study (0-6 months) for all scores while.7 119.979 1 351195.837 0.669 1. those with antisocial PD and mixed PD.874 11694. Ttest results reflecting differences between groups (PD vs.35 df 125. T-test results reflecting differences between groups (PD vs.1 3.008 0.029 .80 6.057 PANSS_G 155. 5).451 0.8 122.708 .05) between the two groups for all scores followed.91 12.38 125.7 3. ANOVA test combined).4 116.874 1 8466.000 . There were no statistically significant correlations between types of PD and other variables.9 122.000 0.008 PANSS_N 181.177 6 months (T1) t Df 3.23 103.546 1 130390.000 28985.677 1 1617053.152 1 101073. and HCR_C.276 1 181.453 0.000 PANSS_G 351195. PANSS_EC.1 124 p .376 .88 126 3.316 PANSS_T 2395. 2015 improvement is only significant for PANSS_N.808 9.38 1.30 12.152 2073.004 .000 PANSS_T 1617053.003 0.546 1822.7 4.92 126 2.000 21972.036 CGI 15.756 -0. The improvement between baseline and endpoint differ significantly between groups (with and without PD) according the effect of interaction time*PD.484 1 2395. Results to ANOVA repetead measures Type III Sum of Source Measure df Mean Square F Sig. Tests of Between-Subjects Effects (ANOVA mixed) reflecting the influence of PD on clinical courseTable 5. CGI-S.419 .506 .406 .8 122.3 125.008 .718 .938 .884 1 15. The clinical course In both groups (with and without PD). in the second period of 6 months (6-12 months).808 1 29.63 1. no PD) on psihopathology and violence risk PANSS_P PANSS_N PANSS_G PANSS_T PANSS_EC CGI_S HCR_C HCR_R Baseline (T0) t 1.786 1 21972. PANSS_G. XVII. vol.000 Table 5.143 .005 .557 0.Romanian Journal of Psychiatry.019 0.39 1. both at 6 months and at endpoint (Table no.46 1.4 123.49 1.532 .000 HCR_C 29.002 Final (T2) t df 3. Post-hoc tests confirm the statistic significance presented.36 105.003 PANSS_EC CGI HCR_C PD Table 4.000 0.358 .786 6943.276 3.505 0.000 .9 2.006 .000.88 126 2. There is no significance for PANSS_P.011 0.000 8466. Table no. HCR_C.000 PANSS_N 101073. and PANSS_T.001 .44 17.85 106.206 0.948 7.231 1.000 .185 0. PANSS_P PANSS_N PANSS_G PANSS_T PANSS_EC CGI_S HCR_R HCR_C df 1.016 .49 9.42 F 5.5 2. clinical improvement was statistically significant (p=0. 95% CI.Monica D Moșescu.000 Table 7. Type of antipsychotic drug used (first generation. participation in OT is an independent factor with statistical significance to clinical improvement in subscales: PANSS_ P (p = 0.003 0.02-17.008. 7).33-8. Observations were confirmed by Kaplan-Meier survival analysis: Log Rank = 16.000) in the PD group which means that the use of antipsychotics in combination was an independent factor for decrease PANSS-EC score. an observation confirmed by KaplanMeyer survival analysis. 1. 95% CI.000 and there were statistically significant differences between the 2 groups on violent behaviour during the study: χ2 (1) =22. Gabriela Costea: Personality Disorders And Psychotic Disorders – Co-morbidity In Forensic Inpatients Violent behaviour PD significantly correlated with violence (Pearson correlation): 0.000) and HCR_C (p = 0. Risk assessment PD mattered significantly for the discharge proposal: χ2(1)=7. A bar chart reflecting relationship between PD and hospital violent behaviour PD PD No PD Overall Comparisons Chidf Square Log Rank (Mantel-Cox) 3. p=. Kaplan Meier survival analysis demonstrated poorer survival (no violence) in PD group 18 Participation in OT is negatively correlated with violence.000. participation in OT does not correlate with clinical improvement than for HCR_C (p = 0. p = 0. .177.35.883 16. 3.743.002). Therapeutic compliance is seen better by participating in OT because pharmacological treatment administration is strictly monitored by medical staff.915 df 1 2 1 2 P 0.000 (Figure 3).001.000 0. time*antipsychotics.201 11. There isn't any interaction effect with statistical significance in the group without PD.000 0. Patients with psychosis and co-morbid PD were more often treated with a combination of antipsychotics than with monotherapy but without statistical significance. In the group without PD.62) Treatment plan There were statistically significant differences between groups regarding the therapeutic plan (chi-square test).6) Patients with PD had a seven times higher risk of having a hospital violent behaviour (OR = 7. PD correlates with poor therapeutic compliance and even with therapeutic resistance. but in the group without co-morbid PD.23) of being proposed for discharge compared to those with PD co- .90) (Figure 4). 95% CI. Results of Kaplan Meyer Analyse reflecting occurence of violence Figure 4.452 19.012) and only for psychotic PD patients.3. Note that patients with schizophrenia and PD participating in OT have a better evolution in terms of positive symptoms and risk factors. Pearson chi-square Ocup_therapy Ocup_therapy systematic Mood stabilizers Antipsychotics χ2 23.649 1 Log Rank (Mantel-Cox) Sig. Patients without PD had a higher likelihood (OR=3. those with PD have a 3.07. p = 0.5. which means that participation in OT can be considered protective factor for the occurrence of violence only in the group without PD.5 times higher risk for repeated violence (OR=3.024).000). Significant difference was observed only for PANSS-EC subscale (p = 0.056. PD correlated significantly with repeated violence: χ2 (1) = 10. HCR_R (p = 0. p = . chi-square test showed a statistical significance between participation in OT and violent behaviour: χ2(1) = 12.150 1 19. combination) does not matter in clinical outcome for patients regardless of the presence of PD. Differences on treatment plan Figure 3. p = 0.000 Table 6.270. PD significantly correlated with: the use of antipsychotics in combination. Alina V Ungureanu. second generation. Magdalena Dragu.076 .63-7.000 (table no. This observation supports the complexity of therapy necessary for these patients (PD co-morbid schizophrenia) with the rising cost of hospitalization. the use of mood stabilizers and low participation in OT (table no. p=. Only in the group without PD. These results are confirmed in mixed ANOVA: there is interaction effect. 1.415. only for PANSS_EC (p=. 45% PD and 10% are dually classified (high security unit) (17).647 0.704 Total 0. Co-morbid PD are also likely to be independent risk factors for violence in individuals with schizophrenia (24. In 5 cases it was diagnosed another type of PD. In other sample of 39 patients: 87 % received a diagnosis of PD. and narcissistic) but also in terms of: gender. in the legal arena it can lead to confusion by making apportionment of responsibility or fault more difficult (23). average age. vol. high co-morbidities and the difficulty of establishing causality (22). No.735 0. 20% assault and 10% sexual offence (17).715 0. XVII. 27% battery or murder) (15) and in UK medium secure unit: 25% murder/attempting murder.2 years) was similar with those of Romanian forensic sample (35. probably because of the lack of victim's courage to recognize their problem.02. 2007 (21) showed that marital status. histrionic. most often from cluster B (14).725 0. Review of the literature reveals limitations in comparing results among previous studies about PD. Alcohol consumption is frequently associated with PD and schizophrenia and it is an independent risk factor for violence seen in the literature data. alcohol abuse. which has implications for early intervention and management (29).Romanian Journal of Psychiatry. In most respects. previous psychiatric hospitalizations were predictors of violent behaviour in schizophrenia (21). but in the same spectrum: F20-F29. p = 0. Regarding the diagnosis of schizophrenia (or other schizophrenia spectrum disorder) there were only 22 cases where the screening diagnosis was different. Personality dysfunction is often a co-morbid condition.654 0. There is an association of homicide with mental disorder. 51 have one PD and only 18 have psychosis and more than half of the patients have had a drug or alcohol problem (15). particularly with schizophrenia. antisocial personality disorder and drug or alcohol abuse (18). undoubtedly.467 No PD 0. the same.25) and personality pathology can be a significant predictor of aggression in patients with schizophrenia (26). the most related to criminal and it is the most connected to alcohol/drug abuse. and their detection and treatment are therefore of primary importance. Better predictivity in schizophrenic group without PD raises questions considering that psychopathy is an H subscale factor (HCR-20) and. Although comorbidity as a clinical concept can increase understanding.703 0. ROC analisys for violence prediction DISCUSSION The first observation is related to underdiagnosis of PD in forensic practice: only 28 (21. PD relationship with violence is complex because of the variety of PD. 58 (36%) were found with one PD and 39 (24%) were diagnosed with schizophrenia and comorbid PD (16). In a German forensic sample (141). measures. HCR-20 scores (total. HCR_risk_assess HCR_R HCR_C HCR_total_score PANSS_EC AUC PD 0. PD correlates with more frequent use of combination of antipsychotics and mood stabilizers and low participation in occupational therapy which resulted in a limited clinical improvement 19 . a large proportion of patients in Dutch forensic hospitals have a PD without a concomitant major mental disorder (12) but.7%) diagnosed at screening. making it difficult to determine direct causation. the same. This was demonstrated by widely differing prevalence rates of personality disorders (11).5 years) (15). There are few data about offenses: patients from German sample have different crime backgrounds (54% sexual offenders.7 to 0.546 0. borderline. There was a statistically significant correlation between the PD and HCR-20 risk-assessed (low. alcohol consumption. Epidemiological data obtained correspond to the literature regarding prevalence PD and co-morbidity with psychotic disorders and prevalence of cluster B PD (antisocial. 86% had schizophrenia and 85% had problematic use of alcohol ( medium security unit) and mean age was 40 years.1. 66% fulfilled diagnostic criteria for a cluster B (13). R).666 0. PANSS_EC and observed an average predictivity (0.735 0. Co-morbidities are frequently implicated in violent behaviour of psychotic patients. and patterns of analysis. In a sample of 162 forensic inpatients from the same Romanian Forensic Hospital (PSMH Sapoca).16) co-morbid schizophrenia (or other schizophrenia spectrum disorder) compared to 65 (50. violent offence was more frequent in group with schizophrenia and co-morbid PD (69%) than without PD (54%) and it is remarkable the absence of sexual offenders in our sample. Mean age (31. In terms of predictive validity for violent behaviour we analyzed HCR-20 risk assessed. In our study. 2015 morbid schizophrenia. In secure hospitals from UK: 88% are men. cluster B PD is predominant: in a sample of 94 patients. Mihailescu and Mihailescu. mean age was 37. Cluster B PD is. the differences from international observations on the HCR20 violence predictivity (10) but can be explained by methodological limitations of the study. C.8%) subjects were diagnosed with PD (generally antisocial PD . medium. 29% wounding. possibly due to variability in the types of populations.758 0. 61% had schizophrenia. offenders with schizophrenia and high levels of psychopathic traits seem to be similar to psychopathic offenders without psychotic illness.75) for the group without PD and a low predictivity for the group with PD (table no. In sharp contrast to our results.81. PD co-morbid schizophrenia was associated with an increased risk for violence and a more complex treatment. The risk of violence in patients with schizophrenia is significantly increased by association with antisocial PD and borderline PD (27) and co-occurrence of schizophrenia and borderline PD is not infrequent and that borderline PD has a significant negative longitudinal impact on the course and outcome of patients with schizophrenia (28). which is a clearly precipitating factor of violence (19) and antisocial PD is a risk factor for developing problem drinking and often antisocial PD develops a few years before the drinking (20).2 years) (16) and German forensic patients (36.623 Table 8. Psychosocial treatments are necessary components of the management of violence in psychosis (30). high): χ2 (2) = 7.8).445 0.712 0. Ihm H. 9. Best specialized mental health services for people with PD and schizophrenia may be provided in specific treatment units for PD patients. Gibbon M. Int J Offender Ther Comp Criminol 2001. of which PD is one (12) and the UK is recognising the importance of mental health awareness and reduction of stigma.International Classification and Statistics of Diseases and Related Health Problems.Adel A. 2006.excited-component of PANSS PANSS_P – PANSS positive score PANSS_N – PANSS negative score PANSS_G – PANSS general psychopathology scale PANSS_T – PANSS total score CGI-S .Positive and Negative Symptom Scale –Scale of positive and negative symptoms in schizophrenia CGI-S . There are 3 inevitable problems related to treatment of violent patients with PD: PD are egosyntonic and PD patients not accessing psychiatric services only in cases of emergency/crisis or when associated another mental disorder (35). simptomatologie și diagnostic clinic. Kotov R. Schizophr Bull 2011. 7. . the benefits of antipsychotics and mood stabilisers might also include reductions in the rates of violent crime (34). Girolamo G. All Educational. patients are likely to receive more accurate assessments and diagnoses. 3.De Ruiter C. Grimm G. available online: www. we believe that assessment and accurate diagnosis as both a psychotic disorder and a co-morbid personality disorder it would facilitate access to complex individualized treatment programs. and has begun to integrate access to treatments with employment services (36). 5. given the methodological limitations of this study. In this context.35(1): 92-97.27: 233–48. 1976. Neil L. Violence and Personality in Forensic Patients. All these issues outline wavy evolution marked by non-compliance and treatment resistance. Targu Mures. 16. 10. 1998.Monica D Moșescu. Alina V Ungureanu. as clinicians become more familiar with the new PD model.Huang Y. ABBREVIATIONS PD – Personality disorder PSMH – Psychiatry and Safety Measures Hospital ICD-10 . Yu R. J Rural Community Psychol 2006. 2. HCR-20 violence risk assessment scheme: Overview and annotated bibliography. Evidence of effective therapeutic programs for PD is limited especially regarding long-term outcomes (including antisocial behaviour): cognitivebehavioural interventions have the best evidence base and pharmacological interventions using mood stabilizers and atypical antipsychotics may be effective for some symptoms of personality disorders (33). 2008. Washington: American Psychiatric Press.Timmerman IGH. MD: National Institute for Mental Health. 1997. Strack M.Fazel S.Structured Clinical Interview for Personality Disorders Clinical PANSS . These problems lead to prolongation of hospitalization and to increased costs during hospitalization.***ICD-10. consistency and intensity of their symptoms (35). 6. 12. problem whose solution is tried with categorical and dimensional hybrid model proposed by DSM 5. 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Methods: We adapted to the Romanian population the RI48. both in terms of the encoding. discriminative. normal cognitive functioning. as well as the retrieval. reliability. Alzheimer's disease. Results: The RI-48-R reliability was good (alpha = 0. RI-48-R. mild cognitive impairment in AD.The occurrence of the retrieval difficulties when encoding specificiy was optimised by coordinating encoding and retrieval conditons is a specific marker of AD. 2. differentiated in terms of cognitive functioning. Four groups of elderly people. cued recall task. 4. A group of Belgian and Swiss researchers have developed a French version of the category cued recall memory task (RI-48) and have proven its psychometric properties. By applying it the AD specific deficits of encoding and retrieval can be assessed. concurrent and predictive validity. dementia in AD. Multiple comparisons between groups revealed intergroups quantitative and qualitative differences. Anca Niculăiţă³ Abstract: Background: Episodic memory impairment has been recognised as the hallmark symptom of Alzheimer disease (AD). Cătălina Tudose². subjective memory complaints.ORIGINAL ARTICLES ADAPTAREA ROMÂNEASCA A PROBEI DE MEMORIE EPISODICĀ CU CODURI SEMANTICE RI-48 Cristina Popescu¹. . . . 3vs4³ Fluenţă verbală 12.85/ 23.43±2.55±1.09/ 7. 7%) 74.97³ KruskalWallis Testul U 1 vs. D .001 26 .53 Medie ± abatere standard Mediana 30 29 29 25 Testul H χ²=83.3².7± 0.45/ 25 AMS M±a.2 5±1 .2/ 95 17.3±4.Demenţă * NS. 2vs.5±10.Tulburare cognitivă uşoară. 2vs3¹. D – Demenţă . 1vs4³ 26 25 24 24 2vs3².s.04±0.3¹.15.31/ H χ²=63. U:1vs3³. 1vs. 1vs4³.Diferenţe nesemnificative statistic R-ACE-R Scor total N M±a.04 14. 2vs4 ³. 3 72.05¹.87±0.43/ 15. TCU-Tulburare cognitivă uşoară.56 AMS 2 29.58³.2%) 18 (60%) 61(62 . U:1vs3¹. ³ p<0. NS* 71./Md 1 96. 2vs3³.27/ H χ²=41.43±2. AMS-Acuze mnezice subiective. 2vs4³.37±2. U:1vs2³.78±6.s. Mann3vs. Anca Niculăiţă: Adaptarea Româneasca A Probei De Memorie Episodicā Cu Coduri Semantice Ri-48 MMSE N N=23 AMS N=30 TCU N=97 D N= 57 Analiza de varianţă SEX: feminin (%) Vârsta 15 (65.4². AMS-Acuze mnezice subiective. 26 14.79±3.07±3. ² p<0.9%) χ²=1. Cătălina Tudose.11 N-Funcţionare cognitivă normală. 2vs3³. 3vs4³ Orientare TS H: χ²=73.15/ H: χ²=44.Cristina Popescu.01.7/ 18 22. 1vs4³.01/ 12.97±0.81³. 2vs.52±3. ² p<0. TCU.6±0.s./Md 2 94.2¹. U:1vs3³.7±5.68.68 14./Md 4 75.19±3. 16 16 16 15 2vs4³.0/ 14.34/ 10.28 ±2. p=0.19±4. 1vs4³.54 35 (54.35± 1. 2vs4³ Vizuo-spaţial 16.001 F=1.26±2. 2vs4³.41 D 4 24.35/ 97 18±0/ 18 24. 3vs4³ Limbaj 25.35.78±2.3/ 18 23.3±1.6±2.65±2.49/ 24 TCU M±a./Md 3 89.37/ 23.67±2.99/ 17 16.32 F=2 p=0. 12 12 11 7 2vs3².15/ 24.83±2.47/ 15.81. 2vs4³.4/ 75 16±1. H: Testul H Kruskal-Wallis. 3vs4³ Memorie H: χ²= 95.47± 5.57±1.06 72.0 4±6 . 1vs3³.05.37± 2.4² Whitney ¹ p<0.35 ³.7/ 16 Comparaţii H: χ²=113.75/ 23 Demenţă M±a.13 ±7.96³.s.6 N 1 29. U:1vs3³.3vs4³ N-Funcţionare cognitivă normală. 1vs4³.16 TCU 3 28. U: Testul U Mann-Whitney ¹ p<0. 1vs. 2vs4³. U:1vs3³.9/ 90 17.13 Instruire 15.4².03± 1. 8 32 3. 2vs4² H:χ²=53.1±7.2 30. subscorul b.4±3. 2vs3¹.3 0. 2015 Variabila EIM-C EIM-G ECIM2 repetari ECIM 3 repetări N M±a. 3vs4² H: χ²=50. 3vs4³ EITC.s. U:1vs2¹.6 1 4.69±0.s Md 3 38.2 H:χ²=45. 2vs4³.s Md 2 41.001 27 .2 43 0.27 EIT-GR 2 ±2.2/±3.56 0.3±0.75±0.5±4.05¹.6±0.6±0. 3vs4² 1 2 3 3 N-Funcţionare cognitivă normală.3±1.2³. 2vs4².38¹.2 0.06³ .9±4.8 17. 2vs4³.2±4.42 3vs4³ EITC-b 0.1.64³.4 H:χ²=61.01.1vs4³. U:1vs3¹.Testul Kruskal-Wallis.regăsiri întârziate corecte.1 0.2 0.4³. 1vs.6±6.4±1.5±0. 1vs4³.6 26. ³ p<0.3³.51±0.3±5. EIT-C.8 39 2.9±3. 1vs4.3±0.08 H::χ²=17. EIT-G.45 0.6 42 1. U:1vs3². U: 1vs3². 0. EIM-G.39³. 3vs4³ H: χ²=45.67 0.5 0.6±3 3.3 4. TCU.8 2 6.6 4 0 AMS M±a.3 3. 3vs4³ 0. No. 1vs4³. U: 1vs3¹.4². 2vs4².grupuri H: χ²=75.14.4±3.06±0.4±3. 3vs4² EIT-C 31±6. 30 28 26 19 2vs4³.65 0. U: 1vs3¹. XVII.6±5 6 2.48³. vol. 2vs3³. U.8 4 19.7 1 3. 1vs4³.2 H: χ²=27. D . 2vs3¹.s Md 4 30.31±0.2 0. U:1vs3¹. U: 1vs2². AMS-Acuze mnezice subiective.a 0. Md 1 42. 2vs4³.Testul Mann-Whitney ¹ p<0.Demenţă EIM-C-regăsiri imediate corecte. 2vs.5 0. EIT-b – regăsire întârziată.69±0. 1vs4³.2 0 TCU M±a.9 5 0.regăsiri întârziate greşite H.Tulburare cognitivă uşoară.9±2.1vs. ² p<0.46 1 Comparatii inter. 1vs3³.2 2.64 0.Romanian Journal of Psychiatry. subscorul a.3±5.2 0. EITaregăsire întârziată.regăsiri imediate greşite.6±4.7 0 D M±a.61³.1vs4³. subscorul b 28 Valoarea prag Sensibi litate Specifi citate Proba de învăţare verbală Rey: evocare 0.8% EINT <0.Cristina Popescu.4% 81. EIMC. subscorul b 0. EITCb Evocare întârziată.446* 0.677* 0. subscorul a. EITa.regăsiri întârziate corecte . EITCa Evocare întârziată.regăsire întârziată.8% 30.89% 65.573* 0. EITb – regăsire întârziată.592* subscorul de memorie * p<0.267* 0.589* întârziată 0.472* 0.7% .6% 90. Cătălina Tudose.517* 0.490* recunoaştere întârziată R-ACE-R. subscorul a.707²* 0. EITCîntârziată.001.1% 87% 88.EINTb <0.503* 0.2% 80.690* 0.586* 0. Anca Niculăiţă: Adaptarea Româneasca A Probei De Memorie Episodicā Cu Coduri Semantice Ri-48 Proba de memorie verbală cu coduri semantice EIMC EITC EITCa EITCb Variabila % Concord anţă <34 89. 0.6 93.5% ECIM <19 98.435* Evocare .615* 0.6 EIM-C-regăsiri imediate corecte.Evocare imediată. EIT-C.4% 69.601²* imediatăscor global l evocare 0.5% -EINTa 93. . . and may be understood as an inability of the child to resist to the constraints of the environment. family drawing. emphasized personality traits. physical or emotional neglect. In the child these risk factors may be: prematurity. Received October 20. being particularly strong in children from 5 months to 3 years. immediate or postponed ones. early institutiona-lization. Affective deprivation produces variable effects depending on its nature (insufficiency. poor socio-economic situation. Chief Physician. social and economic misery. early separations. they were hospitalized in Pediatric Clinic of Neurology and Psychiatry in Tg. MASC. Andrea Gálicz-Nagy 2. Conclusions: Absence of the mother. They were examined clinically and psychology-cally. adaptation disorders. mental vulnerability. Accepted December 19. whose evolution and severity depends on the age of the child at the time of separation and the duration of being apart. Mother-child separation remains a traumatic event. discontinuity) but also on its duration. Pediatric Psychiatry. that represent a risk of mental morbidity superior to the one noticed in the general population. a chronic somatic disease. Revised November 24. with ages between 5. transitory or lasting. 2014 2 31 . child's age and the 1 University of Medicine and Pharmacy Tg. Psychic vulnerability emphasizes the manifested or dormant sensibilities and weaknesses. chronic disagreement in the family. its ability to anticipate events and to alter the course or inability to influence them. of his possibility to anticipate the events and to change their course through its own competence of active adjustment to the environment (1). they were applied different specific scales and questionnaires: STAI-C. The clinical diagnosis was established by the DSM IV-TR ICD-10. 2014. alcoholism.-Mures: resident physician Pediatric Psychiatry. distortion. death of one parent. Material and methods: 47 children were evaluated.Mures. neonatal sufferance. low level of education (11). In the child's family these risk factors may be: parental separation. The child's mental vulnerability is its ability or inability to withstand environmental constraints. IINTRODUCTION In the child's psychopatology.10 and 17. Key words: traumatizing events. chronic disease of a parent. scared-R. Senior Lecturer. twins. and its mental functioning.8 years. This may be the result of the nursling's perception and later of the child.-Mureş. In society there are also a series of risk factors. Results: Separation of mother and child is a traumatic event that modifies child behavior more so how it is smaller. 2014. The child develops an anguished attachment reaction described by Bowlby. CAT. Clinic of Pediatric Neurology and Psychiatry Tg. incomplete couple (single mother). physical abuse. mother-child separation. different life events may represent risk factors for psychic diseases. mental illness of the biological parents. in 2013. Alina Luca 2 Abstract: Introduction: In the child's life occur traumatizing events that can change its behavior. such as: migrant situation. especially if the child is younger. “Risk factors” are all the existential conditions of the child or of the environment. the tempe-rament traits of the child constitutes an etiopathogenic factor determining: cognitive and affective disorders. emotional and behavioral disorders.ORIGINAL ARTICLES PATHOLOGICAL ATTACHMENT: ETIOPATHOGENIC FACTOR IN CHILD PSYCHOPATOLOGY Elisabeta Racoș-Szabo1. psychosomatic manifestations. aggressive behavior. for a long time. it can be noted: psycho-somatic disorders and intercurrent infections: otitis. but cognitive impairment is completely reversible. extended hospitalization. This separation reaction is especially intense in the infant of 5 months old to 3 years old. BDI. BECK. ”the reassuring niche” (6).-Mures. making efforts to limit the number of persons who come in contact with the infant. described by Bowlby as “anguished attachment reaction” (3. superficial friendship relationships. indifference. psychic and language development is almost always retarded. The institutions that take care of nurslings have become aware of the dangers of affective mothering. At the same time appear also a series of psychic manifestations such as: aggressiveness. The patients have been somatically. nocturnal enuresis. due to a multitude of causes such as: institutionalized infant. psychic and language development. relating permanently to the specialized literature data. Repeated separations are very harmful. the results have been interpreted and certain conclusions have been drawn. Certain psychic alterations of the child are more severe and less reversible: verbal impairment. frequent change and replacement of the caregiver.Elisabeta Racoș-szabo.) (8. if onsets in the first year of life and persists for three years. scales and questionnaires (Raven. even hostility (4. innate and destined for survival. If affective separation and deprivation begin in the 2nd year of life. have been admitted 848 children. watching. detached air. indifference towards the caregiver. lack of education. family drawing. presenting symptoms corresponding to the 2 clinical forms: inhibited and disinhibited. somatic disorders: decrease of immunity. among which 47 have been diagnosed with Attachment Disorder according to the DSM IV-TR and ICD 10 criteria. retardation in psychic development but mostly of the language (5). In neglected or maltreated children appear deviant forms of attachment. psycho-somatic disorders: anorexia. and the playing is poor (7. When affective deprivation is severe and extended. age (very young or old parent). 3) has described 3 stages of separation reaction: protest stage. verbal communication. In these children. subsequently by detachment. and reintroduction of the attachment figure may stir up indifference. mother with physical or psychic disorders. which 32 seem irreversible.) both to the child and parents. Mother-infant separation is a frequently encountered event. Children with a sure attachment have better adjustment abilities. “the primordial matrix”. poor social and economic situation (physically neglected child. STAI-C.3). 10).). etc. abstraction function and ability to form profound and durable interpersonal attachments. and they create coping strategies in difficult situations (7. psychosis) making the parent incapable of an appropriate nursing. poverty. 11). both on the cognitive processes development of the child and on its personality development. then in the child of 2-3 years old. The evolution depends on the age at which the separation took place and its duration (1). detachment stage (2 . in 2013. 8). Bowlby. 9). TAT. undiscriminated sociability (7. etc. In the disinhibited form the somatic symptoms encountered are: decrease of immunity and resistance to infections. they do not interact with the adult. essential in the formation of attachment. heredo-collateral factors related to the psychiatric area. 1969 (2. insufferable child. . 8). especially language development. depressive symptoms. These children present a range of diffuse symptomatic manifestations. learning disorders. psychically and psychologically examined. the somatic. sleep disorders. constituting the premise of normal subsequent emotional development. smiling. the child developing an extreme sensibility and a permanent anguish. alcoholism. taking in one's arms and cradling the infant (3. behavior disorders (11). without clothing and appropriate food. noticed typically in nurslings of 5-6 months old. If separation is extended it is noticed: a frequent stopping of the affective and cognitive development. Maternal nursing and commitment in this process represent the early contact between infant and mother. despair. hyper-vigilance. behaviors maintaining closeness are: visual contact. retardation in psychomotor development. In the inhibited form appear a series of somatic and psychic symptoms. 8). The ethiological factors involved are: psychic disorders of the biological parent (depression. Andrea Gálicz-nagy . The psychic symptoms encountered may be: inhibition. in an older child there are noticed school adjustment difficulties. sex and origin of environment. insanitary dwelling. rhinopharyngitis. emotional instability. Attachment behaviors. Amidst the neglectful families there may be cases of “intrafamily hospitalism” (1. nanism. The children's response to a long separation from the attachment figure is manifested initially by protest. translated through an excessive dependence of his environment. CAT. and applied various tests. vomiting. there were performed various paraclinical laboratory investigations.-Mures with different psychiatric clinical diagnoses taking into account they are based on the attachment disorder. aggressiveness etc. temperamental traits of the child (too quiet child. SCARED-R. failure to thrive. 47 children admitted to the Clinic of Pediatric Neurology and Psychiatry Tg. The data obtained has been represented graphically. physical abuse etc. 11). 8). hyperactivity. Maternal deprivation is the lack of positive mother-infant interaction. absence or diminished interaction capacity. The somatic symptoms are: decreased resistance to infections. In anamnesis we monitored data related to the social and family factors. falling ill frequently. MASC. Alina Luca: Pathological Attachment: Etiopathogenic Factor In Child Psychopatology mothering quality that preceded it. institutionalized child. MATERIAL AND METHOD There have been monitored during the year 2013. some children suck their thumb with an absent. The biological mother represents “the primordial figure of attachment”. it has very severe effects. the effects on the personality development are severe. RESULTS In the Clinic of Pediatric Neurology and Psychiatry Tg. representing 6% of the total admissions (Figure 1). The need of attachment is a biological need. subnutrition. despair stage. 4%).-Mures.4%) were male and 35 (74. alcohol consumption. The patients have been somatically. consisting in: verbal impulsiveness: 22 patients (46. extreme poverty with physical neglect: in 11 cases (15.-Mures. applying also different scales and questionnaires both to children and mothers. decrease in school results: 18 patients (38%). alcohol consumption in family 33 . behavior disorders with vagrancy.6 %) female (Figure 2). child abandonment with placement in family type house or maternal assistant: in 18 cases (25. in 2013 The patients have been psychologically assessed by Raven test. Cognitive development level of monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg.6%). The reasons for admission of monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg.-Mures.6%) (Figure 4). Admissions in the Clinic of Pediatric Neurology and Psychiatry Tg. Among which 12 patients (25. in 2013 The reasons for admission were various. morning fatigue. intra-family conflicts: in 13 cases (18. affective. vol. Heredo-collateral antecedents concerning the psychic pathology of the biological parents as a prone factor.1. Heredo-collateral antecedents of monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg. Figure 5. abdominal pains: 13 patients (26%). selfaggressiveness: 5 patients (10. precordial pains. hetero-aggressiveness: 27 patients (57. sad disposition: 17 patients (36%). language development disorders: 5 patients (10. They presented various clinical manifestations: behavioral.8%). Thus it has been outlined: normal intellect in 38 patients (80%).1%). No. hyperkinetic. in 2013 Among the social and family factors with importance in the etiology of attachment disorder. school absenteeism: 8 patients (16%). lie. personality disorders in the families of 5 children (10. hyperactivity. there were pointed out the following: death of a parent: in 6 children (8.57%). The age of patients was between 5. in 2013 Figure 3.71%). disharmonic personality development. smoking: 17 patients (36%).8 years old. 2015 Figure 1. autolytic attempts. thirst for air.71%). theft. liminality in 7 patients (15%) (Figure 6). sleep disorders (insomnia. psychically and psychologically examined. The environment of monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg. affective neglect in family: in 7 cases (10%). Figure 6.-Mures. were emphasized in 10 patients (21. frequent awakenings. statural and ponderal hypotrophy: 8 patients (16%) (Figure 5). at 4 children (8. 2%). instability: 11 patients (22%).5%). in order to establish the cognitive development level. nightmares): 10 patients (21%). somatoform manifestations: cephalalgia. mild mental retardation in 2 patients (4%). in 2013 Figure 4.Romanian Journal of Psychiatry.-Mures. schizophrenia: in 1 case (2. Thus: depression in biological parents.10 and 17.6%). retardation of psychic development: 3 patients (6%). XVII.57%). etc. and family drawing also. At the same time questionnaires were also used for parents. in addition to the psychic examination there were applied different scales such as: STAI-C. they consisted in: voluntary medicine ingestion in 4 cases (8. mood stabilizers (Carbamazepine. Andrea Gálicz-nagy .5%). In cases in which affective deprivation and neglect were emphasized. they have presented either borderline type elements (4 patients: 8. Disharmonic personality development has been outlined in case of 10 patients (21%). Figure 7. Diagnoses of monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg. autolytic attempts: 7 cases (15%). in addition we used ludotherapy and drawing therapy. Case of a patient with Attachment Disorder and repeated autolytic attempts. with disharmonic personality development of borderline type.Elisabeta Racoș-szabo. early . socialized behavior disorder: 17 cases (36%). Disharmonic personality development at monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg. in 2013 Autolytic attempts have been present in 7 patients (15%). mother and brother) (Figure 11). family type house or change of placement. Figure 11. individual psychotherapy of cognitive-behavioral type. BECK. DISCUSSIONS The specialized literature reminds of the fact that certain events in the child's life may be risk factors for psychic diseases and namely: prematurity. not representing himself in the family drawing (only the father. In children with retardation in psychic or language development there has been performed stimulation. or anxious-avoidant type (4 patients: 8. with disharmonic personality development of borderline type Figure 8. disharmonic personality development: 10 cases (21%) (Figure 8). Alina Luca: Pathological Attachment: Etiopathogenic Factor In Child Psychopatology and physical abuse of the child: 15 cases (21. anxious-depressive disorder: 8 cases (16%). CDI. in 2013 For the diagnosis.-Mures. the family drawing has been suggestive. MASC. They have pointed out modifications based on which we could diagnose: ADHD: 5 cases (10. Figure 10. projective tests (CAT.5%) (Figure 10).6%). TAT). in 2013 In case of a patient with Attachment Disorder and repeated autolytic attempts. Figure 9. defenestration: 1 case (2%).43%) (Figure 7). in 2013 34 The specialized treatment of the monitored patients has consisted in anxiolytic medication (Alprazolam). Valproic Acidum). Family factors with importance in the etiology of attachment disorder for admission of monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg.5%). veinsection in 2 cases (4%) (Figure 9). SCARED-R. Autolytic attempts for monitored children admitted in the Clinic of Pediatric Neurology and Psychiatry Tg. or antisocial type (2 patients: 4%). it has been performed a psychological intervention consisting in family counseling. At the same time it has been recommended psychiatric treatment for parents with depression or psychoses and it has been disposed the removal of the child from the natural family and his nursing by grandparents on condition that the family environment stays stable. antidepressants with ISSR (Sertraline).-Mures. it has been disposed social and family reinsertion to maternal assistant. Furthermore.-Mures.-Mures. No. 337-355. Infomedica. 2010. Martin A.30(2): 257-259. Reactive attachment disorder is manifested by: cognitive disorders. Philadelphia: Lippincott Williams and Wilkins. immigrant status. (eds). XVII. Bucureşti : Ed. the child's institutionalization with frequent change of the caregiver. 3. Acad. hyperactivity. duration. family conflicts etc.Bowlby J. undiscriminated socialization etc. either too young or too old. (Psychopathology Treatise of Child and Adolescent Development). New York: Basic Books.Ainsworth M. Vol 1 Attachment. For etiological factor in the attachment disorder there are mentioned in the specialized literature the psychic disorders in biological parents. Chicago: Chicago University Press. J. BIBLIOGRAPHY 1. Child development 1991. psychic diseases of the biological parent incapable of an appropriate nursing. 2009. Attachment in the preschool years. 1978. in 10 cases (21. 2015 separations. the child presenting either frequent intercurrences or somatic development retardation.. Taylor E. the ability to form profound and durable attachments. alcoholism of biological parent. consisting in the retardation of the cognitive development. Depressive disorders in maltreated children.Izard C. 9. or aggressive behavior. low level of education (5.. pronounced personality disorders. conflicts in family. Attachment behaviors mentioned in the specialized literature are: visual contact. Psyhiatry 1991. Attachment and loss. Paris: PUF. Chicago Review of child development research 1979. psycho-somatic manifestations. vol. 2006.Mircea T. in the first year of life having irreversible effects on the cognitive development. early institutionalization. child's age and mothering quality. Tratat de psihopatologia copilului. various personality disorders. biological parent's age. infant cradling. The psychic functions the most severely affected in the children in our trial have been: verbal function. 711-717. poor social and economic situation (11 cases). 4. Greenberg M. which it has been noticed also in the patients included in our trial. (1. Attachement et perte: la separation ongoisse et colere. Bishop D. 446-474.Marcelli D. 229-239. Fifth Edition.M. 6. the abstracting function. adjustment disorders. their absence determining the apparition of the anguished attachment reaction. all the more so as the child is younger. Cummings E. 62. emotional and behavioral disorders.S. 11). anguish and rage). poor social and economic situation. (Child and Adolescent Psychiatry Manual). as well as producing effects on the child's personality. Manual de psihiatria copilului si adolescentului. or psychic retardation or language development retardation.Dobrescu I. 7. Rutter M. Affective deprivations produce variable effects on the child's development depending on their nature. Tratat de psihopatologie a dezvoltarii copilului si adolescentului. 2006. Child Adolesc. (Attachment and loss: separation. et al. Lewis's Child and Adolescent Psychiatry. 2. Emotional determinants of infant-mother attachment. abstracting function. poor social and economic conditions. schizophrenia. Fundaţiei Generaţia. carelessness towards the family. Fourth Edition. atypical families (incomplete couple: single mother). 2007. Am. Cichetti D. 10.3. The development of infant – mother attachment.E. Rutter's Child and Adolescent Psychiatry. conflicts in family (13 cases). Ed. 1990. Pine D. 4). 10. alcohol consumption and physical abuse of the child (15 cases). etc.T.Kaufman I.1. Mother-infant separation is a psycho-traumatic event which changes the child's behavior. These factors have been emphasized also in children from our trial and namely: child abandonment with placement in family type house (18 cases). (Child Psychopathology Treatise).Cicchetti D. In children who are in our trial.D. verbal communication with the infant (3). Volkmar F. 1982.M. 83-87. physical abuse.T.Bowlby J. affective or 35 .28%) it has been emphasized the existence of the psychic disease in the biological parent and namely: depression. An Organizational perspective on attachment beyond infancy.) constitute a etiopathogenic factor (RUTTER). 906-913. *** Affective deprivations (mother's absence. 8. CONCLUSIONS physical neglect. Timisoara: Editura ArtPress. the ability to form profound and durable interpersonal attachments.Romanian Journal of Psychiatry. Blackwell Publishing. 5. There are severely affected: the verbal function. affective neglect of the child by biological parent ( 7 cases). In: Greenberg M. chronic somatic disease. smiling. Cummings E. All authors are responsible for adhering to guidelines on good publication practice. attached to and sent together with the “Authorship Responsibilities” form. royalties) with any organization or entity with a financial interest in or in financial conflict with the subject matter or materials discussed in the manuscript are completely disclosed here or in an attachment. The manuscript should be accompanied by a cover letter including: . 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XVII.84. 28 June 2015 Romanian National Psychiatry Conference Professor Tudor Udriștoiu RNPC Chair Scientific Committee Organizers: WORLD PSYCHIATRIC ASSOCIATION ROMANIAN ASSOCIATION OF PSYCHIATRY AND PSYCHOTHERAPY Professional Congress Organizer: "CAROL DAVILA" UNIVERSITY OF MEDICINE AND PHARMACY UNIVERSITY POLITEHNICA OF BUCHAREST NATIONAL SOCIETY OF FAMILY MEDICINE ROMANIAN PUBLIC HEALTH AND HEALTH MANAGEMENT ASSOCIATION .27 June 2015 The Palace of the Parliament Bucharest.wpa2015bucharest.WPA 2015 BUCHAREST INTERNATIONAL CONGRESS Primary Care Mental Health: Innovation and Transdisciplinarity 24 .org Professor Dinesh Bhugra Congress President Professor Helen Herrman Co-Chair Scientific Committee Professor Eliot Sorel Co-Chair Scientific Committee Professor Masatoshi Takeda Co-Chair Organizing Committee Professor Aurel Nireștean Co-Chair Organizing Committee RNPC Conference President 27 . Romania www. Alina S Rusu.. Gabriela Costea & Romanian Adaptation of Episodic Memory Test with Semantic Codes RI-48 Cristina Popescu. New York) Virgil ENĂTESCU (Member of the Romanian Academy of Medical Sciences. Andrea Gálicz-Nagy. MEZZICH (Professor of Psychiatry and Director. Alina Luca INSTRUCTIONS FOR AUTHORS 14 22 31 36 Romanian Journal of Psychiatry and Psychotherapy is recognized in Romanian National Council for Scientific Research in Higher Education. Washington DC) Maria GRIGOROIU-ŞERBĂNESCU (senior researcher) Tudor UDRIŞTOIU (UMF Craiova) www. Munchen) Eliot SOREL (George Washington University. Department of Psychiatry.ro .Benefits for Patients Ramona L Păunescu. starting with January 2010. at B+ category Ż Romanian Journal of Psychiatry and Psychotherapy is indexed in the international data base Index Copernicus – Journal Master List. TroisRivieres University. Ioana V Micluţia 10 ORIGINAL ARTICLES & Personality Disorders and Psychotic Disorders – Co-Morbidity in Forensic Inpatients Monica D Moșescu. Roxana M Stoean. POSTOLACHE. Mount Sinai School of Medicine. Baltimore) Sorin RIGA (senior researcher) Dan RUJESCU (Head of Psychiatric Genomics and Neurobiology and of Division of Molecular and Clinical Neurobiology. MD (Director. Ż Doctors subscribed to this journal receive 5 CME credits / year. Bogdan E Patrichi. APR ASSOCIATE EDITORS: Doina COZMAN Liana DEHELEAN Marieta GABOŞ GRECU Maria LADEA Cristinel ŞTEFĂNESCU Cătălina TUDOSE Executive editors: Elena CĂLINESCU Valentin MATEI REVIEW ARTICLES & Dan PRELIPCEANU Dragoş MARINESCU Aurel NIREŞTEAN STEERING COMMITTEE: Vasile CHIRIŢĂ (Honorary Member of the Romanian Academy of Medical Sciences. Mood and Anxiety Program. Cătălina Tudose. Magdalena Dragu. University of Maryland School of Medicine. Sackler School of Medicine Tel Aviv Univ. Iaşi) Michael DAVIDSON (Professor.ROMANIAN JOURNAL OF PSYCHIATRY CONTENTS EDITOR-IN-CHIEF: CO-EDITORS: SPECIAL ARTICLES & Cardiovascular Comorbidity Associated with Schizophrenia Spectrum Disorders Veronica Ruşanu. Mirela Manea. Anca Zăgrian. Department of Psychiatry. Mount Sinai School of Medicine. Timişoara) Juan E.romjpsychiat. Quebec) Mircea LĂZĂRESCU (Honorary Member of the Romanian Academy of Medical Sciences. Adrian I Horvath. LudwigMaximilians-University. Satu Mare) Ioana MICLUŢIA (UMF Cluj-Napoca) Şerban IONESCU (Paris VIII Universiy. Veronica Şut. Scientific articles published in the journal are credited with 80 CME credits / article. starting with 2009. Anca Niculăiţă & Pathological Attachment: Etiopathogenic Factor in Child Psychopatology Elisabeta Racoș-Szabo. Alina V Ungureanu. Division of Psychiatric Epidemiology and International Center for Mental Health. Tudor Nireştean. New York University) Teodor T. Alina Frunză 1 & Adult ADHD – A New Entity in Psychiatry (DSM V) Laura Aelenei 4 7 Diagnosing Personality Disorders: A Modern View István Zs Szász. Anna M Tóth & Animal Assisted Therapy. George Moşoia.