COMITET DE REDACIE

Redactor ef:
Dan PRELIPCEANU
Redactor-efi
adjunci:
Drago MARINESCU
Aurel NIRETEAN
COLECTIV REDACIONAL
Doina COZMAN
Liana DEHELEAN
Marieta GABO GRECU
Maria LADEA
Cristinel TEFNESCU
Ctlina TUDOSE
Secretari de redacie: Elena CLINESCU
Valentin MATEI
CONSILIU TIINIFIC
Vasile CHIRI (membru de onoare
al Academiei de tiine Medicale,
Iai)
Michael DAVIDSON (Professor, Sackler
School of Medicine Tel Aviv Univ.,
Mount Sinai School of Medicine,
New York)
Virgil ENTESCU (membru al Academiei de
tiine Medicale, Satu Mare)
Ioana MICLUIA (UMF Cluj-Napoca)
erban IONESCU (Universitatea
Paris VIII, Universitatea TroisRivieres, Quebec)
Mircea LZRESCU (membru de onoare al
Academiei de tiine Medicale,
Timisoara)
Juan E. MEZZICH (Professor of Psychiatry
and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
Sinai School of Medicine, New York
University)
Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Department of Psychiatry,
University of Maryland School of
Medicine, Baltimore)
Sorin RIGA (cercettor principal gr.I)
Dan RUJESCU (Head of Psychiatric
Genomics and Neurobiology
and of Division of Molecular and
Clinical Neurobiology, Department
of Psychiatry, Ludwig- MaximiliansUniversity, Munchen)
Eliot SOREL (George Washington
University, Washington DC)
Maria GRIGOROIU-ERBNESCU
(cercettor principal gr.I)
Tudor UDRITOIU (UMF Craiova)

ARPP

REVISTA
ROMN
de
PSIHIATRIE

ROMANIAN JOURNAL OF PSYCHIATRY

ASOCIAIA ROMN
DE PSIHIATRIE I PSIHOTERAPIE

Vol XVI

www.romjpsychiat.ro

CNCSIS B+

Nr. 4

December 2014

QUARTERLY

p-ISSN: 1454-7848

e-ISSN: 2068-7176

CUPRINS

PROF. DR. FLORIN TUDOSE

(5

octombrie 1952 - 12 octombrie 2014)

109

SPECIAL ARTICLES

SOMATIC CO-MORBIDITIES AND FRAILTY IN

PATIENTS WITH MENTAL DISORDERS

Abstract:
Far from being an exception, presence of somatic comorbidities represents the rule in patients with chronic
mental disorders. Co-morbidities can delay diagnosis, can
influence treatment, are related to complications and
affect survival. From these reasons assessment of comorbidities become a necessity in clinical research. One
assessment method is represented by co-morbidity indices.
These instruments used mainly in research offer a global
assessment of associated diseases' severity and are used
especially for mortality prediction. Co-morbidity indices
exclude the primary disease from impact analysis and
focus only on cumulated effect of coexistent diseases. Comorbidity indices are not, however, direct methods of
assessment on health state, for this purpose performance
scales are used. Frailty, a new concept useful in research
and also in clinical practice, aims to explain the different
evolution of patients with comparable co-morbidity load.
Frailty describes a state of global vulnerability to stressors
that determines an unfavorable prognosis. Studied
especially in elderly, frailty is considered a consequence of
multisystemic physiologic decline encountered in these
category of patients. The defining characteristics of frailty
concept are global physiological impairment and
unfavorable answer to stressors. Proposed modalities for
frailty assessment are multiple, reflecting the lack of
consensus on defining frailty. Some assessment
instruments are centered on identification of a clinical
pattern, others use clinical global impression, and others
use a multidimensional approach (including domains like
mobility, physical activity, nutritional state, cognition,
social support, patient's perception on his own health) or
quantifies the number of deficits. Existence of an
association between mental disorders, somatic comorbidities and frailty remains to be established by future
studies, such studies requiring existance of standardized
instruments.
Key words: polipathology, frail, assessment.

1
MD, PhD student, Assistant Professor, Physiology II Neurosciences Department, Faculty of Medicine, Carol Davila University of Medicine and
Pharmacy, Bucharest, Romania. Contact adress: Mihai Viorel Zamfir, Str. Matei Basarab, Nr. 22, Bl. 100, Sc. A, Ap. 3, Bl. 100, Sc. A, Ap. 3, Rm. Vlcea,
Jud. Vlcea. Email: mihai.zamfir@yahoo.com
2
MD, PhD, Assistant Professor, Psychiatry Department, Clinical Psychiatry Hospital Prof. Dr. Alex. Obregia, Faculty of Medicine, Carol Davila
University of Medicine and Pharmacy, Bucharest, Romania
3
MD, PhD, Geriatrics and Gerontology Professor at Faculty of Medicine, Carol Davila University of Medicine and Pharmacy; Head of Geriatrics and
Gerontology Department at Ana Aslan National Institute of Gerontology and Geriatrics, Bucharest, Romania
Received May 16, 2014, Revised June 13, 2014, Accepted July 18, 2014

110

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

Somatic co-morbidities in patient with mental
disorders represent an important public health issue due to
their negative impact on quality of life and life expectancy,
and also to high costs associated to care. Far from being an
exception, presence of somatic co-morbidities represent
the rule in patients with chronic mental disorders.
Prevalence of chronic somatic disorders in patients with
severe mental disorders reaches up to 74% (1). Factors
contributing to association between mental and somatic
disorders are multiple: stress, high prevalence of mood
disorders, unhealthy behaviors and life-styles, high
prevalence of smoking, alcohol dependence and drugs
addictions, sedentariness, adverse reactions to drugs,
particularly to antipsychotics (that present a high risk for
developing metabolic syndrome and diabetes mellitus) (24).
Patients with schizophrenia present high risk of
somatic morbidity and mortality (5). Life expectancy for
patients with schizophrenia is 20-25 years smaller than for
subjects in general population, and the excess of mortality
cannot be explained only by increased incidence of
suicide (6). Diabetes mellitus and metabolic syndrome are
important complications in patients with schizophrenia.
Prevalence of diabetes mellitus in these patients is
estimated between 9-14%, and the risk of developing
diabetes mellitus is 2-3 times higher in patients with
schizophrenia as compared to general population (7).
Incidence of diabetes mellitus following treatments with
conventional (7.7/1000 years-patient) or atypical
(9.8/1000 years-patient) antipsychotics was higher in
comparison to general population (3.3/1000 yearspatient) in a cohort from Great Britain (8). Adults or
elderly patients with schizophrenia present a 79% increase
in cardiovascular risk as compared to general population
(9). Increased cardiovascular risk is due not only to
diabetes mellitus, but also to dyslipidemia and smoking
(10). Respiratory disorders, including chronic obstructive
pulmonary disease and decreased values of pulmonary
capacity are frequently encountered in patients with
schizophrenia, that present an Odds Ratio for developing
COPD of 1.88 in comparison to general population (11).
Majority of patients with type I or II bipolar
disorder present at least one somatic co-morbidity and
many present multimorbidity (3). Prevalence of
cardiovascular disorders is increased in these patients.
Higher prevalence of arterial hypertension represents an
important risk factor for coronary and cerebro-vascular
ischemic events (12). Prevalence of obesity, metabolic
syndrome and diabetes mellitus are significantly
increased in patients with bipolar disorder (13). Also
patients with bipolar disorder present increased
prevalence of various pulmonary disorders (bronchitis,
COPD, asthma, thromboembolism), situations that can be
explained by aggregation of risk factors for pulmonary
disorders (smoking, obesity, sedentariness, musculoskeletal trauma, hypercoagulability, diabetes mellitus,
drugs addictions) (13, 14). Increasing weight is a side
effect associated with most new generation
antipsychotics, being present especially for olanzapine
and clozapine and more moderate for risperidone and
quetiapine (15). More than half of patients with bipolar
disorders present different forms of addictions, between 669% alcohol dependence and between 14-60% drug
addictions (16, 17), with important impact on somatic
state.

Although existence of co-morbidities in patients

with depression represents the rule, most of therapeutic
trials usually exclude patients with associated medical
disorders. This situation raises questions on the
generalization of the results of these types of studies (4).
On the other hand, in the study WHO World Health Survey
between 9-23% of patients with chronic disorders
presented also depression, values significantly higher in
comparison to persons with no chronic disorders (18). In
STAR*D, with a design that tried to reflect the real profile
of co-morbidities, more that 2/3 patients with depression
presented an associated somatic disorders (19). The
severity of depression is correlated to the level of somatic
co-morbidities (20), and the degree of somatic impairment
is correlated to response to antidepressive treatment and to
the incidence of relapses (21, 22). Older patients with
higher number or severity of somatic co-morbidities,
indicated by the score of Cumulative Illness Rating Scale
for Geriatrics (CIRS-G), presented increased prevalence
of depression and reduced response to the treatment with
paroxetine in comparison to patients with less severe
disorders (22). Depression presents an increased risk for
occurrence and worsening of cardiac disorders. In a metaanalysis, depressive symptoms constituted a significant
risk factor for incident ischemic heart disease with a
Relative Risk (1.64) smaller than that of active smoking
(2.5) but higher than passive smoking (1.25) (23). Also
depressive symptoms present after an acute myocardial
infarction are a risk factor for cumulated mortality (24)
and depression post acute myocardial infarction is
associated with a 2.25 times higher risk for unfavorable
cardiovascular prognosis (25). Anxiety symptoms are also
associated with increased incidence and with progression
of cardiac impairment (26, 27).
Between 10% to 20% of patients with diabetes
mellitus present depression and the percentage rises to
30% for patients with depression diagnosed prior to
diabetes (28). Association of diabetes mellitus with
depression determines a reduced compliance to treatment
and increased risk of macro- and microvascular
complications (29).
The relation between diabetes mellitus and
depression is bidirectional. Presence of depression
constitutes a risk factor for occurrence of diabetes mellitus
and depression treatment is associated with decreased
resistance to insulin, independent of other risk factors
(obesity, alcohol abuse, smoking, family history) (30).
Presence of complications of diabetes mellitus is
associated with decreased answer to cognitive - behavioral
therapy and persistence of depression is associated with
increased levels of HbA1c (31). Similar studies support
the connection between the depression or anxiety and
stroke, Parkinson Disease, irritable bowel syndrome,
cancer, fibromyalgia and pain syndromes (32).
All these data show the association between mental and
somatic co-morbidities and support the fact that
systematic approach of somatic co-morbidities can be
decisive for the prognosis of patients with mental
disorders.
ASSESSMENT OF IMPACT OF CO-MORBIDITIES
Co-morbidities can delay diagnosis, can
influence treatment, are related to occurrence of
complications and can influence survival (33). Due to
these reasons the quantifying of co-morbidities is
111

becoming a necessity both in research and

clinical practice.
One method for assessment of co-morbidities is
represented by co-morbidity indices. Co-morbidity
indices reduce all coexistent disorders to a single
numerical score and allow comparison between patients
with different disorders. These scores offer a global
assessment of severity of coexistent disorders in one
patient. Co-morbidity indices are research instrument
used in prospective or retrospective studies that need
stratifying patients in risk groups. They have three
components in their structure: items represented by comorbidities, a severity scale for assessment of comorbidities and a scoring system.
There are many co-morbidity indices used in
clinical research, depending on the destination they have
been developed for (33,34). Cumulative Illness Rating
Scale (CIRS) was developed to assess co-morbidities load
and probability of survival (35). Kaplan-Feinstein
Classification is an index developed in a group of adults
with diabetes mellitus to prove the impact of comorbidities on prognosis (36). Charlson Co-morbidity
Index is an index used for prediction of short term
mortality (37) and INDEX of Coexistent Disease (ICED)
is an index developed to prove that disorders other then the
primary disorder influence prognosis (38). As a general
rule, co-morbidity indices exclude the primary disorder
from the analyses of impact and are limited to assessment
of cumulated effects of coexistant disorders, that is comorbidities. Co-morbidity indices are not, however, direct
methods of assessment for the impact of disorders on
health status, performance scales (Activities of Daily
Living, Karnofsky etc.) being used for these purposes. In
addition co-morbidity indices are quite coarse to replace
clinical reasoning for specific cases.
THE CONCEPT OF FRAILTY
Numerous studies show that social demographic
parameters and co-morbidities cannot fully explain the
different prognosis of elderly patients. The concept of
frailty aims to reflect different evolutions in patients with
comparable co-morbidity load (39). Frailty is referring to
a state of global vulnerability to stressors, vulnerability
which determines an unfavorable prognosis. Frailty, a
major research theme in geriatrics, is considered a
consequence of multi-systemic physiologic decline
encountered in elderly, representing a transitional state
during a dynamic process of progression from functional
fitness to dependency and death (40). Frail patients are
characterized by functional decline, disabilities, increased
incidence of fractures, frequent hospital admissions and
increased mortality (39).
Currently frailty is distinguished from comorbidities or disabilities, which can coexist with frailty
but are considered distinct phenomena. This situation is
illustrated in Cardiovascular Health Study, in which the
presence of frailty phenotype is partially superposed to the
presence of co-morbidities or disabilities. (41)
The link between frailty, co-morbidities and
disability is complex. Both frailty and co-morbidities
predict onset of disability, disability may worsen frailty
and co-morbidities and co-morbidities can contribute to
frailty onset (42). Similarly, the onset of progression of
chronic disorders and poly-pathology may represent
112

symptoms of frailty (41), (43).

The defining characteristics of frailty concept are
global-multi-systemic physiological impairment and
increased vulnerability to stressors (39). Frailty represents
a multi-systemic vulnerability associated with
accumulation of deficits (dysfunctions), which can be
quantified by a frailty index with predictive value for
different types of outcomes (44).
Multi-systemic impairment translates into a
global alteration of homeostasis and into the occurrence of
decompensation in the presence of reduced level of
stressors (39). It is important to note that frailty
characterizes patients with limited functional reserves,
fact that could explain why relative minor burdens (stress,
infections, dehydration, extreme temperature) are poor
tolerated by these patients.
Among the symptoms of frailty are mobility
decline, increased prevalence of falls, loss of capacity of
self care and functional impairment, poor nutritional state,
sensory deficits, fatigue, decline of muscular strength (39,
42, 43, 44). There is still a debate regarding the inclusion
of cognitive function impairment among the domains of
frailty, some authors emphasizing the physical aspects of
frailty while other having a multidimensional approach
(45, 46).
The consequences of frailty are usually
discussed in terms of mortality, morbidity,
institutionalization, incidence of dependency, sarcopenia,
decrease in quality of life and frequent hospital
admissions (39, 42, 43). Frailty represents a risk factor for
incident Alzheimer's dementia and cognitive decline (47,
48). Other cross-sectional studies show the existence of a
positive correlation between frailty and mood disorders
(43).
The presumed cause of frailty is physiological
decline that occurs in some older people. Multiple
mechanisms are incriminated in frailty occurrence (49):
hormonal deficits, inflammation, oxidative stress,
sarcopenia (decline of muscular mass and strength
associated with ageing). Interestingly, these pathogenic
mechanisms are also present in patients with mental
disorders.
Beyond the debate regarding frailty concept,
today it is accepted that frailty represents an increased risk
state for mortality and other types of poor outcomes:
functional decline, dependency, fracture, hospital
admission (39).
The modalities proposed for frailty assessment are
multiple, reflecting the lack of consensus on defining
this concept (46). Some instruments are focused on the
identification of a clinical pattern (Fried phenotype),
others use global clinical impression (Clinical Frailty
Scale); and others use a multidimensional approach
(including domains like mobility, physical activity,
nutritional status, cognition, social support, patient's
perception on his health) or quantify the number of
deficits (Frailty Index) (45).
The Frailty Phenotype proposed by Fried, an assessment
instrument frequently used in research, is focused on
parameters of physical functionality. Fried phenotype is a
construct that comprises five dimensions:
1. Involuntary weight loss (>5% weight loss in last year);
2. Decreased grip strength;
3.Exhaustion, assessed by questions derived from a

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

depression questionnaire (Center for Epidemiologic
Studies Depression Scale);
4. Decreased walking speed at a normal pace on 5m
distance (<=1m/s);
5. Decreased level of physical activities.
For each criterion specific cut-offs derived from
population studies are used. At >=3 criteria patients are
considered frail, pre-frail at 1-2 criteria, absence of any
criterion defining fit patients. These criteria have been
derived from Cardiovascular Health Study (CHS) and
thereafter validated in numerous studies, frail patients
presenting an increased risk of mortality, functional
decline, dependency and hospitalizations (50).
Clinical Frailty Scale (CFS) is a simple instrument
developed for use by clinicians (51). Clinical Frailty Scale
uses clinician's reasoning on co-morbidities, cognitive
impairment and disability. Patients are divided in seven
categories: fit, well (without signs of active disease); well
with treated co-morbidities; apparently vulnerable
(symptomatic co-morbidities); mildly frail (partial
dependency in instrumental activities of daily living
IADL); moderately frail (partial dependency in activities
of daily living -ADLs- and instrumental activities of daily
living - IADLs); severely frail (total dependency). CFS is
easy to administer and from this point of view it has an
advantage over other more complex instruments. Hence,
clinical judgment on frailty can bring useful information
on patient`s prognosis. In Canadian Study of Health and
Aging, CFS has been proved to be a useful instrument for
prediction of mortality and institutionalization at five
years, having performances comparable to Frailty Index
and Cumulative Illness Rating Scale (51). In the same
study, in a multivariate analysis, every increase with one
stage on CFS presented an increase in middle term (70
months) of mortality with 21,2% and of
institutionalization with 23,9% (51).
Frailty Index. Rockwood et al (51, 52), developed a
frailty index based on identification of deficits in domains
like cognition, mood, ability to communicate, balance,
continence, activities of daily living (ADLs), presence of
co-morbidities. These deficits have been identified during
a population study that selected a group of prognostic
factors (70 factors) for mortality and institutionalization.
Frailty Index is expressed as a ratio between number of
identified deficits and maximum number of possible
deficits. Frailty Index is an argument in favor of the theory
of accumulation of deficits as mechanism for frailty
occurrence, mortality increasing proportionally to the
number of deficits. Useful in research, Frailty Index is
difficult to use in practice due to its complexity.
MODELS WITH MULTIPLE DOMAINS
Many investigators describe a broader frailty model,
including domains like cognition, functionality and social
factors. Most of these models with multiple domains are
the result of statistical analysis and do not propose
pathophysiological explanations for the relationship
between measured parameters at the beginning of the
study and prognostic parameters (45, 46). In addition,
correlation between the results of these models is only
partial, sometimes even quite reduced, which can be
explained by the different instruments used and also by the
fact that they detect different groups of frail patients with
different evolution trajectories (53). There is also the
problem of inclusion of disability in the structure of

instruments for frailty assessment, disability being

considered by expert groups a complication of frailty and
not one of its components.
Among the models with multiple domains, we mention
Frailty Index Comprehensive geriatric Assessment (FICGA), a frailty index based on comprehensive geriatric
assessment (54). Comprehensive geriatric assessment is a
multidimensional, multidisciplinary diagnostic process,
used for assessment of medical, functional and psychosocial problems encountered in older patients. Several
components of comprehensive geriatric assessment are
described in the specialty literature: biological, nutritional
state, polymedication, functionality, risk of falls, mood,
cognition, social network and social support, quality of
life and spirituality. FICGA is an instrument that includes
these components and co-morbidities in a
multidimensional scale for assessment of frailty.
Increased levels of frailty assessed by FI-CGA are
associated with an increased risk of mortality and
institutionalization.
CONCLUSIONS
In the present review we presented a series of data that
highlight the somatic dimension of mental disorders,
classically represented by somatic co-morbidities. A new
category of somatic impairment described especially in
older patients is represented by frailty. The existence of an
association between mental disorders, somatic comorbidities and frailty remains to be established by future
studies, such studies assuming the utilization of
standardized instruments.
ACKNOWLEDGEMENT
This paper is supported by the Sectorial Operational
Programme Human Resources Development (SOP HRD)
2007-2013, financed from the European Social Fund and
by the Romanian Government under the contract number
POSDRU/107/1.5/S/82839.
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47. Gray SL, Anderson ML, Hubbard RA et al. Frailty and incident
dementia. J Gerontol A Biol Sci Med Sci 2013;68(9): 1083-90.
48. Buchman AS, Boyle PA, Wilson RS et al. Frailty is associated with
incident Alzheimer's disease and cognitive decline in the elderly.
Psychosom Med 2007;69(5): 483-9.
49. Fedarko NS. The biology of aging and frailty. Clin Geriatr Med
2011;27(1): 27-37.
50. Vermeulen J, Neyens J, van Rossum E et al. Predicting ADL
disability in community-dwelling elderly people using physical frailty
indicators: a systematic review. BMC Geriatr 2011;11: 33.
51. Rockwood K, Song X, MacKnight C et al. A global clinical measure
of fitness and frailty in elderly people. CMAJ 2005;173(5): 489-95.
52. Searle SD, Mitnitski A, Gahbauer EA et al. A standard procedure for
creating a frailty index. BMC Geriatr 2008;8: 24.
53. Rockwood K, Andrew M, Mitnitski A. A comparison of two
approaches to measuring frailty in elderly people. J Gerontol A Biol Sci
Med Sci 2007;62(7): 738-43.
54. Jones DM, Song X, Rockwood K. Operationalizing a frailty index
from a standardized comprehensive geriatric assessment. J Am Geriatr
Soc 2004;52(11): 1929-33.

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REVIEW ARTICLES

DIMENSIONAL PERSONOLOGICAL
PERSPECTIVE ON SUICIDAL BEHAVIOUR

Abstract:
The existence of the human being is delimited by the two
extremes birth and death. The individual's attitude
towards death is always historically and culturally
conditioned. It swings between a serene balance and
respectively a particular fear or sensibility. Nowadays
death is accepted or rejected according to its meanings.
Human beings integrate temperamental, character,
biographic, archetypal components, but also self-reflexive
abilities. These abilities lead to individual self-awareness
and an understanding of life's meanings which favor selfrealization and a subjective well-being. Ideation and
suicidal conducts are the supreme expression of the loss of
existential meanings. Personality traits are among the
personal factors that have major implications on suicidal
behavior. Having a dimensional perspective on these
traits including taking into account the dimensional
facets of personality leads to a more nuanced
understanding of the suicidal phenomenon as well as the
elaboration of early prevention and intervention
strategies.
Key words: suicidal behavior, personality, dimensional
perspective.
Individual existence is delimitated by two
extremes birth and death. The dynamics of the
individual's ages after birth including childhood,
adolescence, adulthood and aging confirms the cyclical
continuity between life's beginning and end. At a certain
stage in its history, psychoanalysis even hypothesized the
existence of two fundamental instincts of life and of
death, respectively of Eros and Thanatos (1). The last
would represent the inherent tendency of organic life
returning to a preceding state, the inorganic state of
existence.
An individual's attitude towards death has
always been historically and culturally conditioned. In an
animated universe according to the concept of animism
fear of death began as a fear of the dead since it was
believed that they could harm the living (2). On the other
hand and in a later period death was considered
happy according to its significances and to the
individual's situation at that moment. That is why the
Vikings were striving to die with the sword in their hand so
that they could enter Wahalla. The manner in which human
beings view death depends on their preservation instinct,

but also on the stage of life they are going through, so that,
for example, at an advanced age death could be looked at
in a detached manner, like a fatality. On the whole, the
individual's attitude towards death swings between a
serene balance cultivated by the ancient Greeks and a
particular fear or sensibility. (3).
The contemporary individual refuses or
accepts death depending on its meanings. Fear of death
represents in the first place fear of the unknown and the
irreversible. Because of social mores death has become an
external show for the individual frightening most of
the time not the intimate act it should have stayed.
Napoleon said priests and physicians made death
painful. On the other hand, not only death but also life is
often accompanied by suffering, and the fear of death
should not be stronger than the fear of life. Moreover,
taking into account the birth trauma, death has been
compared with birth, "sleep and "oblivion being the
dominants (Barbarin quoted by 3).
In general, the way an individual relates to
life's roles and values influences in an obvious manner the
attitude towards death (4). Thus, pragmatic individuals

MD Psychiatry resident, PhD Candidate, Psychiatry Clinic II, UMF Targu Mures
MD, PhD, Professor, Chief of Psychiatry Department, UMF Targu Mures
MD, PhD, Psychiatry Clinic II, UMF Targu Mures
MD, PhD Candidate, Assistant, Psychiatry Clinic II, UMF Targu Mures
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures
Received July 02, 2014, Revised August 29, 2014, Accepted September 26, 2014

115

who are involved in different activities and roles, with prosocial aptitudes, and have a social support network which
is well represented quantitatively and qualitatively, ignore
the idea of death which is overwhelmed and diluted by the
intensity with which they live their life. In their case
memento mori is actually a reference to carpe diem.
Death may also be ignored, and by those for whom life
represents a mean to achieve a value ideal, a goal, who
enjoy a supra-personal respect and appreciation. The
achievement of such a goal brings about great existential
satisfaction and may lead to a reconciliation with death
which can often be manifested by an attitude of
detachment and courage.
It may be considered that living intensely one's
own life in a pragmatic or idealistic way protects the
individual when confronting the eternity of death. On the
other hand, the scarcity of interpersonal relationships and
existential motivations and values, as well as the
dysfunction in various roles of life, disadvantage the
human being before death which appears with all the
negative connotations that may be attributed to it.
It is a known fact that human beings are
products of self-determination and self-becoming.
Biographical experiences, archetypes and self-reflexive
abilities are progressively integrated throughout a
person's life so that in adulthood one becomes self-aware
and aware of one's relationships with others. Dominant
personality traits are both inherited and acquired through
interaction with other people and with the natural world
(5).
Individual self-awareness means implicitly
knowing one's own qualities and flaws, but also being able
to reflect upon the resemblance with people around you, as
well as the challenge of accessing common existential
values. It allows the creation of a feeling of self-realization
and the access to personal happiness. This not only
means the harmony between physical, mental and
spiritual well-being, but a certain subjective well-being
which may result from this harmony and especially from
the understanding of life's meanings.
The approach to life of the mature person must
harmonize the attitude towards himself with the attitude
towards others seen in their own existential context.
Hence, one might learn that life should not be lived as if it
were eternal, and might be able to find and give meaning to
its end.
The contemporary social culture has a
particular dynamics dominated by the phenomena of
technological advancements, urbanization and population
migrations. The abundance and growing diversity of
material goods and services, life models and lifestyles are
often assault the individual's adaptive expectations and
capacities. Old community traditions and customs are
ignored or presented distortedly, as are spiritual and
religious values and ideals (5).
These incessantly altering socio-cultural
conditions have a negative influence on content and
duration of the individual's developmental stages and may
facilitate the development of dominant individualistic
type traits. People who live for themselves prevail
numerically over those dedicated to certain meta-personal
goals.
The individual's attitude towards himself is
dominated by narcissistic and egocentric arguments and
116

as a result is fragile and becomes vulnerable in relation to

the diversity and incisiveness of existential stimuli. In its
extreme version it may take a dramatic turn that of the
suicidal behavior. Suicide is an act of an extreme severity
of the individual towards himself with multiple
psychological, social, legal and moral meanings (3). Thus,
suicide may mean the cessation of any possibility to ever
again have a conscious experience that precedes the
gesture followed by physical death, it may be a crime, a
sin or an expression of the subject's isolation from the
surrounding world or his marginalization.
The factors involved in the preparation and
course of the suicidal act may be sub-divided into personal
and extra-personal (6). In the first category a first rank
position is occupied by the individual's personality
structure with its dominant traits. The presence of certain
pronounced or disharmonic personality traits may favor
the attempts with both a high survival risk and those with a
low survival risk. But suicidal behavior in the diversity
of its versions may also often be encountered in
harmoniously structured personalities, being caused by
non-personal factors.
Both from a categorical and qualitative
perspective, the most common factors involved in the
suicidal act are, in a descendant order, the borderline type
pathological traits, and the antisocial, hysterical, avoidant,
dependant and obsessive-compulsive types. Cluster A
disharmonic traits favor the so called no prior history
suicides. Different personality types disadvantage the
differentiation between real suicide attempts and those
with a low risk of death. And so a categorical type of
personality prone to suicide cannot be pointed out.
When looking at personality traits, the
dominants in cluster A and C pathological personalities
seem to be the suicidal ideation, ruminations and
representations related to the preparation of the act itself
due to a detachment from the practical, and to the triad of
perfectionism, rigidity and pride. In the case of cluster B
traits, actual suicidal behavior, with high or low survival
risk, is favored by the instability of one's self-image, one's
affective instability, as well as by one's impulsiveaggressive potential.
The dimensional or quantitative perspective
allows the establishment of more complex correlations
between normal personality, pathological personality and
Axis I diseases by facilitating comparative comments. It
ensures a significantly increased accuracy of the diagnosis
and a more nuanced comprehension of the psychobehavioral anomalies (7). The most known and used
dimensional models are the 5 factors model the 'BigFive' and Cloninger's 7 factors model the psychobiological model.
In case of the 5 factors model, each trait has six
corresponding facets which allow a much finer
dimensional validation of the diagnosis. Thus, among the
facets of neuroticism that is of the dimension
corresponding to the affective stability - fear, pessimism,
attitudinal fragility and shyness may favor suicidal
ideation and behavior. By the same token, the facets of
either extroversion, activism and spirit of adventure or
solitude, resignation, passivity and anhedonia - inability to
enjoy, may also play an enhancing role in suicidal ideation
and behavior.
With respect to the conscientiousness or

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

perseverance dimension, its extreme components such
as perfectionism, sense of order and duty, reflexivity,
respectively negligence, carelessness, unpredictability,
lack of personal purposes and hedonism which
express low levels related to it may all favor selfsuppressive behavior.
Agreeableness or charm through components
such as optimism, honesty, altruism, modesty or empathy
lower the risk of and preoccupation with suicidal acts. The
facets of spiritual openness such as fantasy, esthetic sense,
curiosity, sensations seeking, openness to novelty and
faith may be other factors non-conducive to suicidal
ideation and acts.
Overall, suicidal behavior is enhanced by high
levels of neuroticism and low levels of extroversion, and
also by extreme values increased respectively
diminished - of conscientiousness. It is disadvantaged by
high values of agreeableness and spiritual openness. It is a
confirmed fact that the high level of impulsiveness,
aggressiveness and affective lability as well as of
perfectionism and rigorousness may favor suicidal
behavior. These traits corresponds to antisocial,
borderline and obsessive-compulsive type personalities.
When relating dimensional personality
reference points to demographic factors one sees that the
pathological dimensions which favor the suicidal act such
as impulsiveness and affective-attitudinal instability
prevail at a young age, while perfectionism and
rigorousness have the same influence at a more advanced
age. In males, high-mortality risk suicide attempts are
prevalent, while in females the risk of mortality is
diminished.
From a dimensional perspective of the psychobiological model of the seven factors four of
temperament and three of character the suicidal behavior
may be favored by the high values of dominant inherited
dimensions novelty seeking, harm avoidance, reward
dependence and persistence. High values of character
dimensions such as self-directedness, cooperativeness
and self-transcendence are a protective factor as to the

suicidal phenomenon. This particularly complex

personological model may allow a correlations with
genetic and biological factors by means of the integrated
neuromediators dopamine, serotonin, noradrenalin and
gamma aminobutyric acid.
It can be stated that ideation and suicidal
attempts are disadvantaged by the structuring quality of
the Self regarded as an individual strategic pole and by the
complexity of interpersonal relationships, so by the
relational social pole of the individual. The spiritual
dimension or pole of the person has the same role,
particularly through the ability for self-transcendence.
Any attempt at comprehending the suicidal
phenomenon and of elaborating prevention strategies
must integrate a dimensional assessment of the personality
inclusively according to its facets that may offer data of
a particular value.
We cannot forget that the human being is the
only one who knows he is here on Earth just in passing, and
that is why he must while seeking happiness and not the
end of life - dare, hope and believe. The individual can
accomplish this by cultivating self-esteem, inner harmony,
with the surrounding people, nature and the cosmos.
REFERENCES
1.Freud S. La psychopatologie de la vie quotidienne. Paris: Payrot, 1924.
2.Eliade M. Fragmentarium. Bucharest: Ed.Vremea, 1939.
3.Athanasiu A. Elemente de psihologie medical. Ed.Medical,
Bucharest, 1983.
4.Baumgarten F. Der weltgelbundene und der lebensgebunkkiene Typus.
Arbeit und Leistung 1966;20(7-8): 119.
5.Lzrescu M, Niretean A. Tulburarea de personalitate. Iai:
Ed.Polirom, 2007.
6.Cosman D. Compendiu de suicidologie. Cluj Napoca: Ed.Casa Crii
de tiin, 2006.
7.Dehelean P, Dehelean M, Dehelean L. O problem controversat:
modelul categorial versus dimensional al tulburrilor de personalitate.
Perspectiva categorial i cea dimensional n cadrul tulburrilor de
personalitate. In: Niretean A (eds.) Personalitatea ntre anormaliti
biologice i interpretri culturale. Tg.Mure: Ed.University Press, 2005,
43-72.

***

117

REVIEW ARTICLES

CLINICAL INSTRUMENTS FOR THE EVALUATION

OF SUICIDE RISK AN OVERVIEW
Ana-Maria Exergian1
Abstract:
Suicide and suicidality are serious health-problems worldwide. In most instances suicide is a complication of
psychiatric disorders, especially mood disorders. Yet, most
people suffering from these disorders do not commit
suicide. At present, there are no clinical or biological
means that can accurately predict who will commit suicide
and who will not. The importance of the subject and the
difficulty of assessing suicide risk have led to the creation
of numerous clinical instruments meant to assist in this
endevour. The multitude of such instruments can make it
difficult for a physician to decide which scale or interview
to use in a particular instance. This overview aims to
present general characteristics and psychometric data
regarding some of the clinical instruments available for
the assessment of suicide risk.
Key words: suicide risk, mood disorders, clinical scales.

INTRODUCTION
Suicide is a serious health-problem world-wide
and one of the main emergencies in psychiatric practice.
Completed suicide is responsible of 1% of all deaths and is
included, in most regions of the world, in the first ten
causes of death (1). It is even higher in rank in adolescents
and young adults: in ages 15-29 it is the second cause of
death and in ages 30-49 the fifth (1). More than that,
suicide and suicidal behaviour have serious social,
economic and psychological influences impacting both the
persons who commit them, their families and other people
close to them.
In most instances, suicide is a complication of
psychiatric disorders. Approximately 90% of those who
die by suicide have, at the time of death, a psychiatric
diagnosis (1, 2), most of them a diagnosis of mood disorder
(2, 3). Yet, most people who suffer from a mental illness
never even attempt suicide. A study published in 2003
estimated that the suicide rate of affective disorders is
193:100.000, meaning that over 99.000 people suffering
from a mood disorder will never die by suicide (4).
Therefore it is very important to be able to distinguish
those few who are at risk.
Up to date there is no available method that can
accurately distinguish those who will commit suicide from
those who will not.
The importance and the difficulty of the task of
identifying those who are at risk for suicide has lead to an
extensive research on the subject, and to the elaboration of

numerous clinical instruments meant for this purpose.

This review aims to describe some of those instruments,
focusing on those that have proven psychometric
properties, in order to guide clinicians searching for an aid
in evaluating suicide risk. The author does not presume to
be comprehensive in this review, since the number of
instruments available is extensive and many of these are
not sustained by a significant evidence basis.
The instruments are presented in several
categories: checklists, clinician-rated instruments, selfreport instruments, combined administration instruments,
measures of suicide attempt lethality, brief screening
measures and scales relating to protective factors. No
instruments created for specific populations (adolescents,
elderly etc.) were included.
CHECKLISTS
This type of instrument is the first to appear in
clinical practice and, most of these early tools have little
or no documented reliability and validity. Among these
we can include: the Scale for Predicting Subsequent
Suicidal Behaviour (5), the Instrument for the Evaluation
of Suicide Potential (6) and the Scale for Assessing
Suicide Risk (7). At present, the existence of these
instruments has more of a historical importance than a
clinical one.

1
Psychiatry specialist MD, PhD Student, Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, No 10 Berceni Road, Bucharest, Romania. Assistant
Professor, Psychiatry department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; tel: 0724.471.471; e-mail:
am.exergian@gmail.com
Received August 25, 2014, Revised October 06, 2014, Accepted October 31, 2014

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Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

1.CLINICIAN-RATED INSTRUMENTS
1.1 Scale for Suicide Ideation (SSI)
This is one of the most widely used instruments
for assessing suicide risk, partly due to its extensive
documentation regarding validity and reliability.
It was published in 1979 by Beck et al. (8). It
contains 21 items, of which 5 are screening items (3
regarding the wish to die passive suicidal ideation and 2
regarding the wish to attempt suicide active suicidal
ideation) and 2 are additional items which assess the
incidence and frequency of prior suicide attempts (these
items are not scored). The total score is calculated by
adding the scores of each item, ranging from 0 (none) to 2
(moderate to strong).
Factorial analysis has determined 3 significant
dimensions: active suicidal desire, specific plans
regarding suicide and passive suicidal desire (8).
It has Cronbach coefficient alphas that show
moderately high internal consistency 0.84 (9) to 0.89 (8).
It also has high interrater reliability, with a correlation of
up to 0.98 (8, 9).
The validity of the SSI was established
repeatedly. In the original work, Beck et al found a
significant correlation with the self-harm items from the
Beck Depression Inventory (BDI) (8). Other studies found
significant correlations with previous suicide attempts,
severity of depression and daily self-monitoring of
suicidal ideation (9, 10). It has been proven that the SSI
can discriminate suicide attempters from nonattempters
(11).
It was found that a total score higher than 2
includes the patient in a higher risk category and suggests
a likelihood of suicide that is 7 times higher than for those
with scores of 2 or less (12).
Main advantages of this instrument are:
extensive use in research, well documented validity and
reliability in a variety of populations, and, according to
some authors the fact that it is administered as an interview
(13, 14) . One possible disadvantage is the fact that it has to
be administered by trained clinicians (14).
1.2 Scale for Suicide Ideation Worst (SSI-W)
This scale was published in 1999 by Beck et al.
and contains 19 items scored 0 to 2, according to suicidal
intensity. The SSI-W measures suicidality (behaviors,
thoughts, emotions) at its worst point in the patient's life.
As with SSI, the total score ranges from 0 to 38 (15).
Factorial analysis has found two factors:
preparation and motivation (15).
The Cronbach alpha was found to be 0.88,
representing moderately-high internal consistency (9).
The instrument has high interrater reliability (9). Its
validity was established by correlation with the suicide
item from Hamilton Depression Rating Scale (HAM-D)
and the suicide item of the BDI (9).
It was found that a score higher than 10
delineated a group of patients who were 14 times more
likely to commit suicide, than those with lower scores
(15).
1.3 Suicide Intent Scale (SIS)
This instrument is comprised of 15 items
designed to measure the seriousness of the intent to die
regarding the most recent suicide attempt. It rates
behaviour and communication prior to and during this
suicide attempt (preparation, execution, setting of the

attempt, whether or not there were attempts to

communicate the intention directly or indirectly,
purpose, expectations).
Factor analysis have reported between 2 and 6
factors (16, 17).
The Cronbach alpha showed high internal
reliability (0.95) (15).
Predictive validity has been studied in two
prospective studies that had a 10 years follow-up period.
In neither of these studies the SIS was able to predict
completed suicide (18, 19).
1.4 Suicide trigger scale (STS-3)
This is a 42-item clinician-administered
questionnaire, with answers ranging from 0 (not at all) to 2
(a lot). It was devised to assess a clinical entity named by
the authors suicide trigger state as a measure of acute
suicide risk (20).
It has demonstrated a high internal consistency
(Cronbach alpha 0.94) (20).
Factor analysis lead to the identification of 3
subscales: frantic hopelessness (12 items), ruminative
flooding (10 items) and near psychotic somatisation (7
items) (20).
The STS-3 total score correlated with the
severity of current suicide ideation. Scores were also
higher in those with a history of suicide (20).
A very recent study has shown that a transformed
scoring (a distance from median of the initial scoring) was
able to predict suicide attempts following discharge in a
high-risk group of suicidal inpatients (21).
2.SELF-REPORT INSTRUMENTS
2.1 Beck Scale for Suicide Ideation (BSI)
This is a 21-item self-administered version of the
SSI. It assesses the patient's suicidality during the week
prior to evaluation (22). As for the SSI, there are 19 scored
items (0 to 2) which yield a total score of up to 38, and 2
additional items which document the existence of
previous suicide attempts and the level of intent regarding
these attempts.
Factorial analysis has delineated 3 factors: desire
for death, preparation for suicide and actual suicide desire
(23). There are two additional items that did not load any
factor: deterrents to death and deception/concealment
(23).
Cronbach alpha coefficients have been found to
be high (up to 0.97) (22, 23). Regarding validity, it has
been found that it correlates highly with SSI (22), but only
moderately with the suicide item in the BDI.
Predictive validity has not been studied.
This instrument holds an advantage compared to
the SSI, for patients who are more comfortable answering
difficult questions in self-report format than in an
interview (14).
2.2 Beck Hopelessness Scale (BHS)
This instrument was created by Beck and Steer
and includes 20 statements which are rated as true or false.
It assesses negative beliefs (pessimism) about the future
(24).
Factorial analysis has revealed 2 factors:
pessimism about the future and resignation. A later study
has found that many of the items are redundant, and most
of the variation of scores is due to a single statement: The
future appears dark to me (25).
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Ana-maria Exergian: Clinical Instruments For The Evaluation Of Suicide Risk An Overview

The validity of the BHS has been proven by the

findings of higher scores in suicide attempters versus
nonattempters (11, 26). Also, significant correlations were
found between BHS scores and SIS scores (27, 28).
The predictive validity of the scale has been well
documented. Beck et al. found, in 1989, that a score of 9 or
above on the BHS suggested a suicide risk 11 times higher
than for scores below 8 (18). A study published in 1990 has
found that BHS scores are the best predictors of eventual
suicide in the long term (over 1 year) (29).
2.3 Self-Monitoring Suicide Ideation Scale (SMSI)
This instrument was developed by Clum and
Curtin in 1993 (30). It consists of 3 items adapted from the
SSI: Today I have had thoughts of making an actual
suicide attempt scored 0 (none) to 3 (strong), Today I
have thought about making an active suicide attempt
scored 0 (not at all) to 4 (continuously) and Today I have
felt that the control I have over making an active suicide
attempt was scored (strong; no doubt I had control) to 3
(absent; no sense of control).
It is designed to be used on a daily basis and to
document fluctuations in level of suicidal ideation (30).
The SMSI items were moderately correlated with
scores on the SSI, and significantly correlated with the
Beck Hopelessness Scale (BHS) (30).
2.4 Suicide Probability Scale (SPS)
It was developed by Cull and Gill and published
in 1988 (31). It consists of 36 items scored from 1 (None,
or a little of the time) to 4 (Most of the time). It has 4
subscales: hopelessness, suicidal ideation, negative selfevaluation and hostility.
Factor analysis has delineated 7 factors: ideation,
hopelessness, positive outlook, interpersonal closeness,
hostility and angry impulsivity (31).
Cronbach alpha coefficients shows high internal
reliability (0.93) (31).
The authors have shown that the SPS can
differentiate among normals, psychiatric inpatients and
suicide attempters (31). The total score was significantly
correlated with the BHS and the BDI (32).
Its predictive value has not been tested.
2.5 Positive and Negative Suicide Ideation Inventory
(PANSI)
This is an instrument that evaluates positive and
negative thoughts related to suicide attempts in the form of
a 20 item self-report. Each item is scored taking into
account symptoms present the previous 2 weeks, from 1
(none of the time) to 5 (most of the time) (33).
Factorial analysis has proven the presence of two
factors: positive and negative ideation (33).
Coefficient alphas ranged from 0.80 to 0.93 for
both factors, underlining a high internal reliability (33).
The authors have documented a generally
moderate correlation to items from the Suicide
Behaviours Questionnaire, but the psychometric
properties of this scale need further research (33).
2.6 Adult Suicidal Ideation Questionnaire (ASIQ)
This instrument was developed by Reynolds and
was published in 1991. It consists of 25 items scored from
0 (never had the thought) to 6 (almost every day). It
measures frequency of suicidal thoughts and behaviour in
the month prior to evaluation and the perceived response
of others to a suicide attempt and, also, the degree of belief
in suicide as a solution to problems (34).
120

Factorial analysis has proven that this instrument

evaluates a single dimension of suicidality (35).
The ASIQ has high internal consistency
Cronbach alpha 0.96-0.98 (34, 35). Regarding validity, it
was shown that there is significant correlation with the
suicide item of HAM-D (34).
The predictive validity has been studied in 1999,
and it was found that ASIQ significantly predicted
suicides in a sample of psychiatric inpatients (35).
2.7 Suicide Ideation Scale (SIS)
This is a 10-item self-report scale that evaluates
severity of suicidal ideation during the year preceding
assessment. The total score ranges from 10 to 50, each
item being scored from 1 (Never or none of the time) to
5 (Always or a great many times) (36).
Cronbach alpha coefficient shows high level of
internal consistency (0.86) (36).
SIS scores were moderately correlated with the
BHS (36).
Psychometric properties of this scale have
insufficiently been tested. Also there is no study regarding
predictive value.
2.8 Firestone Assessment of Self-Destructive Thoughts
(FAST)
This is a 84 item instrument assessing current
frequency of self-destructive thoughts. Each item is rated
from 0 (never) to 4 (most of the time). It contains 4
subscales: self-defeating, addictions, self-annihilating
and suicide intent (37).
Factor analysis has found three factors: selfdefeating (includes: self-depreciation, self-denial, cynical
attitudes, isolation, self-contempt), addictions (consists of
8 addiction items) and self-annihilating (includes:
hopelessness, giving up, self-harm, suicide plans and
suicide injections) (37).
Cronbach's alpha coefficients have shown high
internal consistency of the total score and the four
subscales (0.84 to 0.97) (37).
Total scores and scores on subscales have been
significantly correlated with BDI, BHS and BSI (37).
Further research is required to assess FAST's
predictive ability.
2.9 Suicide Behaviours Questionnaire (SBQ)
The current version of the SBQ is an abbreviated
version of a 7-page clinician-rated interview (developed
by Linehan, unpublished), described by Cole in 1988 (38).
It consists of 4 items: Have you ever thought about or
attempted to kill yourself? (scores 1-6); How often have
you thought about killing yourself in the past year?
(scores 1-5); Have you ever told someone that you were
going to commit suicide, or that you might do it? (scores
1-3) and How likely is it that you will attempt suicide
someday? (scores 1-5).
Internal consistency is adequate (Cronbach alpha
0.75-0.80) (39).
Validity has been tested and it was shown that scores
correlated significantly with the SSI scores (39). Also it
was shown that there was a significant inverse correlation
with RLI scores (14, 39).
There is no data available on predictive validity.
A 34 item revised version of the SBQ (SBQ-14)
was created in 1996 by Linehan (unpublished). The SBQ14 assesses 14 suicidal behaviours in 5 areas: past suicidal
ideation, future suicidal ideation, past suicide threats,

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

future suicide attempts and likelihood of dying in a future
suicide attempt. The questionnaire also evaluates: lifetime
suicidal behaviour, current suicide plan, availability of
lethal methods, social deterrents, attitudes towards suicide
and distress tolerance.
Factor analysis has shown that SBQ-14 is onedimensional (39).
Internal reliability is high (Chronbach alpha
0.73-0.92) and validity was proven by a significant
correlation with the RLI (negative correlation) (39).
The main advantage of this instrument is its
simplicity and its clarity, which make it a viable screening
tool. This is also its greatest disadvantage, because it is
very easy to conceal suicidality should the patient decide
to do so.
2.10 Life Orientation Inventory (LOI)
This instrument was developed by Kowalchuk
and King in 1988 and has two variants: one for screening
which consists of 30 questions and one for profiling which
consists of 113 questions (grouped in six subscales: selfesteem vulnerability, overinvestment, overdetermined
misery, affective domination, alienation and suicide
tenability). All items have answers ranging from 0 (I am
sure I disagree) to 4 (I am sure I agree) (14).
The Cronbach alpha is high (0.90), showing a
high internal consistency (14).
Validity has been shown by the instrument's
ability to discriminate between controls, depressed
persons, possibly suicidal patients and high risk suicidal
patients (14).
There is no proven predictive value.
This instrument has a unique advantage in that its
long version has three validity indices: positive bias,
column responses indicative of inattentiveness to the
content of the items and spoiled or missing (14).
3.COMBINED RATING SCALES
3.1 Inventory of Potential Suicide (IPS)
It is a checklist type instrument that was
published by Zung in 1974 (40). It contains 69 items of
which 50 are clinical and its main advantage is the fact that
it has 3 different versions: one clinical report (physician
rated), one self-report and one reported by significant
other (40).
It has little to none published research on validity
and reliability, but the different versions make it worth
mentioning.
3.2 Suicide Status Form (SSF)
This instrument measures psychological pain,
external stressors, emotional upset, hopelessness, low
self-regard and overall risk of suicide, using 12 items 6
self-report and 6 clinician-administered. Each item is
scored 1 (low) to 5 (high) (41).
It was reported that there is a high level of
agreement between clinician-administered and self-report
items (42). But there was only a moderately inverse
correlation with the Reasons for Living Scale.
Nevertheless, the SSF was able to differentiate
significantly suicidal ideation that had resolved from
chronic one (41).
There is no data regarding the predictive ability
of the instrument. Its main advantage is the combination of
clinician-rated and safe-report in the assessment of suicide
risk.

4 . M E A S U R E S O F S U I C I D E AT T E M P T
LETHALITY
We include in this review some examples of
measures used for suicide attempt lethality because of the
importance of this element has been proven in the
evaluation of suicide risk (43).
Risk-Rescue Rating (44, 45) a clinicianadministered 10 item scale that measures the lethality and
the suicidal intent of a suicide attempt.
Self-Inflicted Injury Severity Form (46) a
clinician-administered 7 item interview designed for use
in emergency departments in order to identify selfinflicted injuries that are life-threatening.
Lethality of Suicide Attempt Rating Scale (47)
a clinician-administered scale designed to measure the
lethality of a suicide attempt. It has 11 items. The total
score ranges from 0 (death is impossible as a result of the
suicidal behaviour) to 10 (death is almost certain
regardless of the intervention of an outside agent; most
people will die quickly after such an attempt). It is
generally considered that a score above 3 signifies that the
attempt is a medically serious one (14).
5.BRIEF SCREENING MEASURES
5.1 Sad Persons
It was published by Patterson et al in 1983 and it
comprises 10 items, several of which are known
demographic risk factors (sex, age and not living with
family or a partner). Other items are: depression, previous
suicide attempts, alcohol abuse, loss of rational thinking,
lack of social support, organised plan of suicide and
somatic illness. Items are scored as 0 absent or 1
present (48).
A modified version of the scale was published in
1988 (MSPS Modified SAD PERSONS score). It also
has 10 items, some different from the original version. The
main difference is due to the assignment of scores 0-2 to
some items (depression or hopelessness, rational thinking
loss and stated future intent determined to repeat or
ambivalent). The importance of this version is that it was
validated for use in screening of patients who require
psychiatric hospitalisation due to suicide risk. Thus a score
of 6 or more suggests the need for hospital admission. The
authors found that this cut-off score resulted in 94%
sensibility and 71% specificity (49).
5.2 Paykel Suicide Items
This is a 5-question interview. The questions
have increasing levels of suicidal intent: 1) Have you
ever felt that life was not worth living?; 2) Have you
ever wished you were dead? for instance, that you could
go to sleep and not wake up?; 3) Have you ever thought
of taking your life, even if you would not really do it?; 4)
Have you ever reached the point where you seriously
considered taking your life or perhaps made plans how
you would go about doing it? and 5) Have you ever
made an attempt to take your life?. The level of the last
question with a positive answer is the score of the scale
(50).
Internal consistency, validity and predictive
value have not been adequately assessed.
5.3 Hamilton Depression Rating Scale (Suicide Item)
It is a clinician-reported item, scored from 0 to 4,
as follows: absent, feels life is not worth living or any
thoughts of possible death to self, wishes he were dead,
121

Ana-maria Exergian: Clinical Instruments For The Evaluation Of Suicide Risk An Overview

suicidal ideas or gestures, attempts at suicide (51).

The validity was established by a significant
correlation with the SSI score and with the sore of the
suicide item on the BDI (14).
Brown et al found that patients with scores of 2 or
higher were almost 5 times more likely to commit suicide,
thus establishing predictive validity (12).
5.4 Beck Depression Inventory (Suicide Item)
This is a self-report item with a 4 point rating: 1
I don't have any thoughts of killing myself, 2 I have
thoughts of killing myself, but I would not carry them
out, 3 I would like to kill myself and 4 I would kill
myself if I had the chance (12).
Brown et al found that patients with scores of 2 or
higher were almost 7 times more likely to commit suicide
(12).
6.SCALES RELATING TO PROTECTIVE
FACTORS
6.1 Reasons for Living Inventory (RLI)
This is the most widely used instrument
assessing protective factors against suicide. It consists of
48 items and is a self-report clinical tool. The items are
grouped in 6 subscales: survival and coping beliefs,
responsibility to family, child-related concerns, fear of
suicide, fear of social disapproval and moral objections to
suicide. Each item is scored from 1 (not at all important)
to 6 (extremely important) (52).
The RLI has shown high internal reliability
(Cronbach alpha 0.89 for the total score) (52).
The survival and coping subscale was compared
to BDI, BHS (53) and SSI (54) and it was found that there
was a significant negative correlation. Also it was found
that the RLI can distinguish between suicide attempters
and ideators and between suicide attempters and
psychiatric controls (11, 35).
There are also available an extended 72-item
version and a brief 12-item version (55).
CONCLUSIONS
There are numerous clinical suicide assessment
instruments described in the literature. Many of them have
been studied, some more extensively than others,
regarding their psychometric properties.
The main difficulty encountered when using
clinical instruments is a low degree of specificity
(meaning many false positive cases). Another
disadvantage is the high reliance on the patient's sincerity.
Also, many of the scales or questionnaires described do
not differentiate between acute and chronic suicide risk.
Another conclusion that can be drawn from this
work is that, although, many of the instruments presented
evaluate the suicidal process, meaning that, to some extent
they are complementary and not interchangeable. This is
why it is important to make an informed choice when
applying a certain clinical instrument to an individual
situation. This choice has to take into account the specific
reason for the evaluation, the viability and reliability of the
instrument regarding this evaluation, whether or not it has
been applied to the population the patient pertains to etc.
One instrument seems to stand out: the STS-3. It
is a newly developed interview, the only one that was
created specifically for the evaluation of acute suicide
risk. Also, it tries to resolve another major problem
122

encountered by other clinical instruments: the reliance on

the patient's sincerity.
Further research is needed in the assessment of
suicidal crises (acute suicide risk) since this
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***

123

ORIGINAL ARTICLES

COMPARATIVE DIMENSIONAL APPROACH OF

PERSONALITY DISORDERS THROUGH THE
MODELS OF BIG FIVE AND BIG SEVEN

Abstract:
Introduction: The dimensional models of personality have
gained ground in the area of trait psychology, fact proven
by the introduction of the alternative DSM-5 model.
Objectives: The aim of the study was to find correlations
between the dimensions of Big five and Big seven.
Method: A group of patients (N= 44) from our Personality
Disorders Register were included in this study. They filled
out two self-administered, paper-and-pencil tests: the
Temperament and Character Inventory(TCI) and the
Disposition (Openness)- ExtraversionC o n s c i e n t i o u s n e s s - A g re e a b i l n e s s - E m o t i o n a l
Stability(DECAS) Inventory.
Results: We have found moderate positive correlation
between Disposition and Self-Transcendence (r=0.51;
p=0.0004) respective Disposition and Persistence (r=56;
p=0.0001) and a strong negative correlation between
Disposition and Harm Avoidance (r=-0.64; p=0.0001).
Extroversion was correlated with Self-Transcendence
(r=0.4; p=0.0044), Novelty Seeking (r=0.43; p=0.0031),
Harm Avoidance (r=-0.72; p=0.0001) and Persistence
(r=0.45; p=0.0021). Conscientiousness is correlated with
Self-Transcendence (r=0.49; p=0.0006), Harm avoidance
(r=-0.5; p=0.0005) and Persistence (r=0.43; p=0.0031).
We have found a moderate positive correlation between
Agreeabilness and Harm Avoidance (r=0.45; p=0.0019).
Conclusions: The comparative comments of the
dimensional evaluation places a premium on the diagnosis
of personality disorders. Self-transcendence has a major
role in understanding personality disorders in any socioculture.
Key words: Personality disorder, alternative DSM-5
model, dimensional models of personality, TCI, DECAS.
processes, DSM-5, neuropsychology
INTRODUCTION
Personality disorders (PD) have always constituted a
major problem in psychiatry, because of the impact they
have on our society. Understanding personality and its
disorders helps us to develop much more sophisticated
treatment guidelines and prophylactic measures. The
DSM-IV diagnostic criteria for PD uses a categorical
approach and this way is not much of a help in an
individualized treatment strategy. This latter assumption
led researchers adopt an opening towards dimensional
approaches. Phenotypic trait personality models have a
better precision in clinical settings then developmental
personality models but are not useful to describe
1

underlying intrapsychic processes(1). The Big five

model is a phenotypic trait personality model which was
developed to assess normal personality but being a
dimensional model it can be used to assess pathological
personality too. Although this model cannot be used to
diagnose PD, low scores on agreeabilness and emotional
stability can be a predictor of pathologic personality traits.
A developmental personality model is the Big seven
which was developed for normal and pathologic
personality, thus it is useful in the diagnosis of PD.
Deficiencies of the character, namely low scores on selfdirection and cooperativeness prove the presence of a
PD.(2)

MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures. Correspondence: szaszisti2009@yahoo.com
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.
3
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.
4
Medical Student, University of Medicine and Pharmacy, Targu Mures
Received July 09, 2014, Revised September 01, 2014, Accepted October 03, 2014
2

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Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

OBJECTIVE
Our aim was to compare the dimensions of the big five
theory with the dimensions of the seven factor model, in
the hope of finding correlations between them, and this
way strengthening the link between different dimensional
models.
MATERIAL AND METHODS
A group of patients(N= 44) from our Personality
Disorders Register were included in this study. This
register contains recorded data from patients diagnosed
with PD between 2011 and 2014 at the Psychiatric Clinic
II in Tirgu Mures.
In our study we used the data of two self-administered,
paper-and-pencil tests: the Temperament and Character
Inventory(TCI) and the
Disposition (Openess)Extraversion-Conscientiousness-AgreeabilnessEmotional Stability(DECAS) Inventory.
Ethical rules regarding informed consent and
confidentiality were applied. Data where processed using
Microsoft Excel(Microsoft Corp., Redmond, WA, USA)
and GraphPad InStat. Linear(Pearson) correlation test was
used calculate the correlation between different
dimensions.
RESULTS
Descriptive statistics
Summed scores of the item pools where examined for
each dimension (Table 1, Table 2)
Mean
SD
Kolmog
orovSmirnov
Test

D
47.20
10.8
passed

E
42.06
11.1
passed

C
43.81
10.6
passed

A
45.40
9.41
passed

S
41.85
7.5
passed

Table 1. The mean, standard deviation(SD) and normality test for

the summed scores of the DECAS dimensions.
Sd
25.6
3
5.67
pass
ed

Mean

Co
26.4
0
5.25
pass
ed

St
13.5
9
6.03
pass
ed

Ns
15.9
0
5.53
pass
ed

Ha
21.9
5
7.82
pass
ed

Rd
12.6
3
3.4
pass
ed

P
3.77

SD
1.58
Kolmogorov
pass
-Smirnov
ed
Test
Table 2. The mean, standard deviation(SD) and normality test for
the summed scores of the TCI factors. Sd- self-directed; Cocooperative; St- self-transcendent; Ns- Novelty seeking; HaHarm avoidance; Rd- reward dependence; P- persistence

Dimensionality assessment
Table 3 shows the correlation coefficients(r) between the
dimensions of TCI and DECAS.
Sd
D
E
C
A
S

Co
-0.28

0.27
0.34
0.29

St
0.51
0.40
0.49
-0.37

Ns
0.43

Ha
-0.64
-0.72
-0.50
0.45
-0.28

Rd
0.31
0.27

P
0.56
0.45
0.43

Table 3. Correlations between the dimensions of TCI and

DECAS; only significant correlations are shown; moderate and
strong(r > 0.4 or r < -0.4) correlations in bold.
Sd- self-directed; Co- cooperative; St- self-transcendent; NsNovelty seeking; Ha- Harm avoidance; Rd- reward

dependence; P- persistence; D- Disposition (Openess); EExtraversion; C-Conscientiousness; A-Agreeabilness; SEmotional Stability

DISCUSSIONS
Disposition
We have found no significant correlation between
disposition and self-direction, cooperativeness and
novelty seeking. The moderate positive correlation
between disposition and self-transcendence can be
explained if we analyse the facets of these dimensions. A
person who is acquiescent, insightful, transpersonal,
creative and spiritual will surely have opening for fantasy,
aesthetics, feelings, actions, ideas and values. An
interesting result is the moderate positive correlation
between disposition and persistence. At first sight it is hard
to explain this correlation. The question is how can we
connect persistence and openness in the case of PD. The
best example for a PD with high scores on persistence is
the obsessive-compulsive PD (OCPD). The link between
persistence and openness to values becomes obvious
through this type of PD which has a hypertrophic
superego.
Extraversion
This dimension of the Big five model is known to have
high scores at PDs of cluster B and from the perspective of
the Big seven model cluster B can be characterized with
high scores of novelty-seeking, confirming the positive
correlation we have found in our study. The negative
correlation between extraversion and cooperativeness is
also easy to understand through the cluster B PDs. The
strong negative correlation between extraversion and
harm avoidance can be understood through the cluster C
PDs: persons
who have high scores of warmth,
gregariousness, assertiveness, activity, excitementseeking and positive emotions will definitely have low
scores on the facets of harm avoidance, namely this
persons can be described as optimistic, daring, autgoing
and energetic.
Conscientiousness
Our study has once again confirm the positive correlation
between conscientiousness and persistence both having
high scores in the case of an OCPD.
Agreeabilness
As we mentioned above PDs can be described as low
scorers on agreeabilness and emotional stability from the
perspective of the Big five model and low scorers on selfdirection and cooperativeness from the perspective of the
Big seven model. This fact made our study group expect
positive correlations between these dimensions as we can
see our study has confirmed these correlations finding
positive correlation between agreeabilness and
cooperativeness respective emotional Stability
and self-direction. The moderate positive correlation
between agreeabilness and harm avoidance can be
explained through the component facets of these
dimensions: altruist , modest, tender-minded, people are
usually seen as fearful and shy.
Emotional Stability
Was find to be negatively correlated with harm avoidance
in other words the opposite pole of emotional stability is
positively correlated with the above mentioned Big seven
factor. Persons who are described as anxious, depressive
and vulnerable could be described as being pessimistic
fearful, shy and fatigable.
125

CONCLUSIONS
The study confirms once again the value of the
dimensional approach in understanding normal and
pathologic personality.
The comparative comments of the dimensional evaluation
places a premium on the diagnosis of PDs
Except emotional stability, self-transcendence correlates
with all of the dimensions of the Big five model which was
validated transculturally. Self-transcendence has a major

126

role in understanding PDs in any socio-culture.

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2009.
2.Cloninger C R. The temperament and character inventory (TCI): A
guide to its development and use. St. Louis, MO: Center for
Psychobiology of Personality: Washington University, 1994.

***

ORIGINAL ARTICLES

IRRITABILITY AND PERSONALITY TRAITS

AS SUICIDE RISK FACTORS IN DEPRESSION
Ana-Maria Exergian1, Liana Kobylinska2, Maria Ladea3
Abstract:
Background: Suicide is one of the main psychiatric
emergencies and an important health problem in most
countries around the world. The highest risk for suicide
among psychiatric disorders is for mood disorders.
Objective: Our study evaluated the impact of trait
impulsivity, trait aggression, irritability and low tolerance
to frustration on suicide risk in depression.
Method: This study was done on a sample of 103 male
inpatients, hospitalized with a diagnosis of Depressive
Episode, regardless of the mood disorder diagnosed
(unipolar depression, bipolar disorder or mood disorder
due to a medical condition). Patients were evaluated by
clinical interview and self-reported scales. As an outcome
variable (to test suicide risk) involuntary hospitalization
was used.
Results: Statistical analysis of the data showed a
significant correlation between suicide risk and
impulsivity (p<0.001), aggression (p=0.059) and low
tolerance to frustration (p=0.003). Irritability (p=0.266)
had no significant correlation with suicide risk, but was
highly correlated with the presence of impulsivity
(p<0.001) and aggression (p<0.001).
Conclusions: Our study confirms the importance of the
evaluation of trait impulsivity and trait aggression in
suicide risk assessment. Further research is needed
regarding irritability and low tolerance to frustration as
suicide risk factors.
Key Words: suicide, irritability, impulsivity, aggression,
depression.

INTRODUCTION
Suicide is one of the main psychiatric
emergencies and an important public health problem in
most countries around the world (1). The evaluation of
suicide risk is one of the core competencies a psychiatrist
has to develop during his training and professional life.
This evaluation is a complex problem, which involves
assessing and integrating numerous risk factors. To date
there is no clinical or biological instrument that can
accurately predict suicide.
The presence of mental illness is one of the most
important factors that increase suicide risk, being present
in 90% of all suicides (2). Studies have shown that two
thirds of these suicides associated with mental illness are
associated with depression. Nevertheless, the great
majority of people who suffer from a mental illness do not

kill themselves and do not even attempt suicide. This fact

led Mann et al to propose, in 1999, a diathesis model. This
model comprises of two facets of the suicidal patient: a
tendency to experience more suicidal ideation and a
tendency to be more impulsive, therefore more likely to act
on suicidal thoughts and feelings (3). Thus, these authors
are among the first to raise awareness to the importance of
impulsivity as a predictor of suicidal behavior. Since then
there have been many studies that have taken into account
impulsivity as a factor in suicide risk.
Also, completed suicide is up to three times more
frequent among men, although there are more attempted
suicides among women (4). This is due, at least in part, to
the fact that men tend to use more lethal means in hurting
themselves. For this reason the present research focuses on
the suicide risk of men with depressive episodes.

1
Psychiatry specialist MD, PhD Student, Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, No 10 Berceni Road, Bucharest, Romania. Assistant
Professor, Psychiatry department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; tel: 0724.471.471; e-mail:
am.exergian@gmail.com
2
Child and adolescent psychiatry resident, MD, PhD student Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, Bucharest, Romania; Assistant
Professor, Physiology department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
3
Senior psychiatrist, MD, PhD, Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, No 10 Berceni Road, Bucharest, Romania. Associate Professor,
Psychiatry department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Received June 16, 2014, Revised August 18, 2014, Accepted September 08, 2014

127

Ana-maria Exergian, Liana Kobylinska, Maria Ladea: Irritability And Personality Traits As Suicide Risk Factors In
Depression
Suicide risk and impulsivity have also been connected to
aggression. This is both due to the fact that suicide is
viewed as aggression turned inwards and to the fact that all
three of these factors have been linked to serotonin
regulation abnormalities (5, 6, 7).
Therefore this study aims to study the link
between suicide risk and trait impulsivity and trait
aggression. Another hypothesis we want to test is that the
degree of irritability developed during a depressive
episode is related to the overall aggression and impulsivity
of the individual and whether this symptom is relevant in
the evaluation of suicide risk. Also we aim to evaluate the
importance of low tolerance to frustration for the suicide
risk of a depressive episode.
METHOD
This study included a cohort of 103 male
inpatients. It was conducted in the 3rd Department of Prof.
Dr. Al. Obregia Clinical Hospital of Psychiatry in
Bucharest, over a period of two years. Patients with a
diagnosis of Depressive Episode were included,
regardless of the type of mood disorder diagnosed
unipolar depression, bipolar disorder or depressive
disorder due to a general medical condition. Comorbidity
(either psychiatric or somatic) was not a criteria for
exclusion from the study. DSM IV-TR criteria were used
to diagnose the depressive episode. As an independent
outcome variable for the evaluation of suicide risk we
used the type of hospitalization (either voluntary or
involuntary). The involuntary hospitalization was
determined by a commission composed of three
professionals, according to the Romanian Mental Health
Law. The study included only those patients with
depressive episodes for whom the involuntary
hospitalization was decided on the basis of suicide risk.
Each patient was interviewed upon admission
and they also completed two self-administered
questionnaires: the Barratt Impulsiveness Scale (BIS) and
the Brief Aggression Questionnaire (BAQ).
BIS is a self-administered questionnaire
consisting of 30 Likert-type items scored from 1
(rarely/never) to 4 (almost always/always) that evaluates
overall impulsiveness. It contains several subscales that
score attentional impulsiveness (attention and cognitive
instability), motor impulsiveness (motor and
perseverance) and lack of planning (self-control and
cognitive complexity).
The BAQ is a self-administered questionnaire
derived from the Aggression Questionnaire developed by
Buss and Perry in 1992. It consists of 12 Likert-type items
scored from 1 (extremely uncharacteristic of me) to 7
(extremely characteristic of me). The BAQ evaluates
overall aggression as a sum of four categories: physical
aggression, verbal aggression, anger and hostility.
The Hamilton Depression Rating Scale
(HAMD-17) and the Clinical Global Impression Severity
Scale (CGIs) were used to confirm the presence of a
depressive episode and to evaluate its severity.
The data was analyzed using SPSS 16.0 and
Microsoft Office Excel. As the tested variables were
ordinal, non-parametric tests were performed.
RESULTS
The group studied was comprised of 103 male
128

patients, with ages between 18 and 80 years old (mean age

45). The age distribution was 13% (n=14) 18-29 years old,
43% (n=44) 30-49 years old, 41% (n=42) 50-69 years old
and 3% (n=3) 70+ years old. Three quarters of the patients
(n=77) resided in urban areas and 25% of them (n=26)
resided in rural areas.
More than half (55%, n=57) were either married
or living with a stable partner, 21% (n=22) were never
married, 19% (n=19) were divorced and 5% (n=5) were
widowed. A small fraction of the patients (18%, n=19)
were living alone, the rest living with family or friends
(82%, n=84).
Most of the patients (61%, n=63) had a high
school level education, 18% of them (n=18) had a lower
level education and the rest (21%, n=22) had a higher level
education. A large number of patients (43%, n=44) were
either on pensions or disability, 29% (n=30) had a stable
employment, 11% (n=11) had an unstable employment
and 17% (n=18) were unemployed.
Regarding the intensity of the present depressive
episode, in most cases it was severe, either with or without
psychotic symptoms (53%, n=55 and 26%, n=27
respectively). A small number of patients (19%, n=19) had
a medium intensity depressive episode and a minority
(2%, n=2) had a low intensity depressive episode. This
distribution reflects the fact that, generally only the more
severe depressive episodes require hospitalization.
The patients (n=103) were divided into two
groups according to the type of hospitalization (voluntary
or involuntary).

Fig. 1. Distribution of the types of admission in the studied

sample. 56 patients were voluntarily hospitalized, while 47 were
hospitalized on a involuntary basis.

1.Tolerance to frustration
The patients with involuntary admission had a
significantly lower tolerance to frustration than the ones
with voluntary admission (Mann-Whitney U=881.5,
n1=47, n2=56, p=0.003), with more patients having a very
low tolerance to frustration in the involuntary admission
group (fig.2-4).
2.Impulsivity
The impulsivity scores of the involuntarily
admitted patients were higher than those of the patients
with voluntary admission (Mann-Whitney U=805.5,
n1=47, n2=56, p<0.001) , with more patients in the
involuntary admittance group having high scores on the
BIS. (fig. 5-7)
3.Aggression
There was a marginal statistical difference
between the aggressiveness scores in favour of the
patients with involuntary admission (Mann-Whitney
U=1042, n1=47, n2=56, p=0.059) (fig.8-10).

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

Fig. 2. Boxplots of the distribution of the low tolerance to

frustration scores in the (n1=47) and voluntary (n2=56)
admittance groups (p=0.003).

Fig. 5. Boxplots of the distribution of the impulsivity scores in

the involuntary (n1=47) and voluntary(n2=56) admittance
groups (p<0.001)

Fig. 3. Prevalence of specific low tolerance to frustration scores

in the patients with involuntary (n1=47) admission

Fig. 6. Prevalence of specific impulsivity scores in the patients

with involuntary (n1=47) admission

Fig. 4. Prevalence of specific low tolerance to frustration scores

in the patients with voluntary (n2=56) admissio
n

Fig. 7. Prevalence of specific impulsivity scores in the patients

with voluntary (n2=56) admission

129

Ana-maria Exergian, Liana Kobylinska, Maria Ladea: Irritability And Personality Traits As Suicide Risk Factors In
Depression
4.Irritability
There were no significant differences between
the two groups regarding the irritability scores (n1=47,
n2=56, Mann-Whitney U=1160, p=0.266).
The irritability scores were strongly correlated
with the aggressiveness ones (Spearman's correlation
coefficient= 0.727, p<0.001) , as well as with the
impulsivity scores (Spearman's correlation coefficient=
0.671, p<0.001)(table 1).
Correlations

irritability

irritability impulsivity aggressiveness

Correlation
1.000
Coefficient
Sig. (2tailed)

impulsivity
aggressiveness

Spearman's rho

Fig. 8. Boxplots of the distribution of the aggressiveness scores

in the involuntary (n1=47) and voluntary (n2=56) admittance
groups (p=0.059)

.671**

.727**

.000

.000

103

103

103

1.000

.758**

Correlation
.671**
Coefficient
Sig. (2tailed)

.000

.000

103

103

103

.758**

1.000

Correlation
.727**
Coefficient
Sig. (2tailed)

.000

.000

103

103

103

**. Correlation is significant at the

0.01 level (2-tailed).

Table 1. The correlations between the scores on the irritability,

impulsivity and aggressiveness scales

Fig. 9. Prevalence of specific aggressiveness scores in the

patients with involuntary (n1=47) admission

5.Personality disorders
There were no differences in incidence of
voluntary or non-voluntary hospitalization when taking
into account each type of personality disorder (Chisquare=4.806, p=0.187, n=103) (table 2). But personality
disorder comorbidity (taken as a whole) was more
frequent in patients that were hospitalized involuntarily
than in those with voluntary hospitalization (53.19% vs
32.14%) (Mann-Whitney U=1035, n1=47, n2=56,
p=0.035) fig. 11 and fig. 12.
Frequencies
personality disorder type

Fig. 10. Prevalence of specific aggressiveness scores in the

patients with voluntary (n2=56) admission

130

Involuntary

cluster cluster cluster

A
B
C
mixed

22

16

voluntary

Admission type

absent

38

11

Table 2. Number of patients with voluntary/involuntary

admission distributed according to the personality disorders

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

Fig. 11. Personality disorders in patients with involuntary

admission (n=47).

Fig. 12. Prevalence of personality disorders in patients with

voluntary admission (n2=56)

DISCUSSIONS
Apart from the behavioural correlation stressed
by Mann et al., depression and impulsivity seem to be also
linked on a molecular level. Serotonin regulation
abnormalities have been tied to both irritability and
depressed mood (5, 6, 7). The same neurotransmitter has
been implicated in the mediation of other
psychopathological traits like aggression and anxiety (5,
6, 7).
In a study on patients with major affective
disorders, Oquendo et al slightly modified the diathesis
model created by Mann et al. (3), stating that persons who
go on to commit suicidal acts after a depressive episode
tend to develop more pessimism in response to a stressor
and/or have aggressive/impulsive traits (8).
In a review of empirical studies, published in
2001, it was found that impulsivity and aggression were
traits consistently associated with completed suicide (9).
In another study that compared serious and non-serious
suicide attempters, it was found that in the first group there
were significantly higher impulsivity, violence, anger-in
and anger-out scores (10). Perroud et al., in 2011, studied a
sample of patients with major affective disorders. It was

found that impulsive and aggressive traits strongly

correlated
in suicide attempters, independent of
diagnosis, but impulsivity distinguished suicide
attempters from non-attempters only in the major
depressive disorder group, and not in the bipolar disorder
group (11). In a psychological autopsy study of 351
suicides, McGirr et al found that impulsivity was a valid
risk factor for suicide (12). There are many other studies
that found impulsivity and aggression as valid suicide risk
factors (13, 14, 15, 16, 17). One review found that the
information available regarding anger, irritability and
hostility as suicide risk factors is insufficient and more
research is needed (18).
A paper published by Oquendo et al in 2000
found that in bipolar suicide attempters compared with
bipolar non-attempters there was more lifetime aggression
but not more lifetime impulsivity (19). One review,
published in 2013, found that impulsivity is not a predictor
for repeated suicide attempts (20). Other studies found a
correlation between irritability (21, 22, 23, 24, 25, 26, 27,
28) and aggression (29, 30), but not both, and suicide risk.
Our data also found that impulsivity and
aggressivity were correlated with suicide risk (p<0.001,
p=0.059 respectively).
Another strong correlation found in our sample
was between aggression/impulsivity and the irritability
present during the present depressive episode (p<0.001 in
both cases), but there was no significant correlation
between irritability and suicide risk (p=0.266). In the
literature we found few studies that addressed the issue of
irritability as a suicide risk factor (31, 32, 33, 34, 35, 36).
The results of these studies are in contradiction: three of
them found a correlation (32, 33, 34) while the other three
found no statistical significance regarding irritability as a
suicide risk factor (31, 35, 36). This is an area that requires
further research.
The high correlation between trait
aggression/impulsivity and irritability is an interesting
find suggesting that a subtype of patients might present
with a predominantly irritable clinical aspect of the
depressive episode. This is of particular importance in the
diagnosis of a depressive episode, since irritability is not
included as a symptom either in the DSM IV-TR criteria or
in most scales that evaluate depression. It would be easy to
misdiagnose such a patient. As a consequence, the
patient's suicide risk might be evaluated as being lower
that it actually is.
In our sample we also found a strong correlation
between a low tolerance to frustration and suicide risk
(p=0.003). This is an area where virtually no research
exists. Generally, this variable has been associated with
personality disorders. While it is true that in our sample
patients with comorbid personality disorders were more
frequent in the suicide risk group, the high correlation
between a low tolerance to frustration and suicide risk was
not fully explained by the existence of this comorbidity.
LIMITATIONS
This study was conducted on male inpatients.
Further research is needed in order to determine whether
these results can be extrapolated to the general population.
CONCLUSIONS
The data obtained from our study confirms the
importance of evaluating trait impulsivity and trait
131

Ana-maria Exergian, Liana Kobylinska, Maria Ladea: Irritability And Personality Traits As Suicide Risk Factors In
Depression
aggression while evaluating suicide risk in depressive
male patients. The degree of irritability was not correlated
with suicide risk in our sample, but this is an area that has
had little research and a definite conclusion cannot be
drawn as yet. A possible new suicide risk factor was
identified as being low tolerance to frustration. Further
research is needed in this area.
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***

ORIGINAL ARTICLES

QUALITY OF LIFE AND PSYCHIATRIC

SYMPTOMS IN PARANOID SCHIZOPHRENIA
Anca L. Atudorei1
Abstract:
Introduction: Quality of life is a multifaceted concept
regarded as an important outcome in chronic disease
treatment, but there is still no consensus regarding its
determinants for individuals suffering from schizophrenia.
Objectives: The study aims at underlining particularities
regarding the quality of life in paranoid schizophrenia
outpatients.
Methods: 60 randomly selected participants were
assessed with Short Form-36 Questionnaire (SF-36) and
Positive and Negative Syndrome Scale (PANSS) in order to
perform a correlational analysis.
Results: In this study, quality of life was not related to
positive or negative symptoms of paranoid schizophrenia,
but there was a negative connection between the selfreported mental health and general psychopathology.
Among the general symptoms, depression, guilt feelings,
unusual thought content, poor attention, anxiety and
tension correlated in a negative ratio with the quality of
life.
Conclusions: Hopefully, the findings will contribute to a
better understanding of the specific needs of paranoid
schizophrenia patients and will be applicable to
psychotherapeutic programs focused on enhancing the
quality of life in this nosographic category.
Key words: chronic psychiatric disease, community
psychiatry, psychotherapy.

INTRODUCTION
A complex psychopathological reality, that affects not
only the person, but the family and the comunity,
schizophrenia is even nowadays a challenge, both from a
pathogenic point of view and a therapeutic one. While
early treatments aimed to reduce the symptoms, modern
ones are approaching the illness from a broader
perspective, encompassing biological, psychological and
social factors. This is why the concept of quality of life
(QoL) is considered nowadays as a key outcome variable
in schizophrenia.
Although the concept of is broadly accepted, there is no
unanimously accepted definition for it. During the past 30
years, various definitions were proposed, raging from a
focus on psychological aspects as feelings of well-being or
satisfaction, to different living standards like perceived
health, finances, housing or employment status.
Assessing QoL in schizophrenia patients is also a
subject of intense debate in scientific community. The
main area of discussion regards the use of objective versus
subjective ratings. While some argue that reality distortion

and the deficit syndrome narrows the patient's ability to

perceive and assess correctly external cues, objective
assessments, conducted by clinicians, were not
consistently correlated with subjective ratings. However,
in an attempt to reconcile the quest for subjectivity with
the question of reliability, Voruganti, Heslegrave, Awad,
and Seeman concluded that clinically compliant and
stable patients with schizophrenia can evaluate and report
their quality of life with a high degree of reliability and
concurrent validity, implying that self-report measures are
potentially useful tools in clinical trials and outcome
studies (1). For the patients with a lower degree of
compliancy or in an acute phase, a complete and reliable
Qol assessment should also include input from the health
care, rehabilitation, family, and community systems.
Another issue where consensus was not reached
regards the relationship between the psychiatric symptoms
and Qol in schizophrenia.
Many studies emphasized a connection between the
two measures. Voruganti, Heslegrave, Awad, and Seeman
(1) found that psychopathology, as determined by total

1
Seinor Psychologist , Phd. Student, Dr.Gavril Curteanu City Clinical Hospital, str. Louis Pasteur. nr.26, Oradea, 410154, Romnia. Phone No:
0747 274 961, e-mail: atudorei_anca@yahoo.com
Home adress: str. Transilvaniei, nr,27, bl.B53, ap.42, Oradea, Bihor, 410387, Romnia
Received June 02, 2014, Revised August 04, 2014, Accepted September 01, 2014.

133

Anca L. Atudorei: Quality Of Life And Psychiatric Symptoms In Paranoid Schizophrenia

134

MATHERIAL AND METHOD

Objectives
This is a quantitative research that aims at underlining
quality of life particularities in relation with paranoid
schizophrenia symptoms, hoping that the findings will
contribute to the development of complex therapeutic
programs that encompass the bio-psycho-social
implications of this chronic and debilitating disease.
Hypotheses
Hypothesis 1: We presume that there is a connection
between the quality of life and the severity of positive
symptoms in paranoid schizophrenia outpatients.
Hypothesis 2: We presume that there is a connection
between the quality of life and the severity of negative
symptoms in paranoid schizophrenia outpatients.
Hypothesis 3: We presume that there is a connection
between the quality of life and the severity of general
pathology in paranoid schizophrenia outpatients.
Participants
The study comprises 60 randomly selected participants
from the patients that addressed the Dr. Gavril Curteanu
City Clinical Hospital Oradea between October 2011 and
January 2012 as outpatients.
There were admitted in the research patients over the
age of 18 that were diagnosed with paranoid
schizophrenia and were following an ambulatory
antipsychotic treatment.
Participants with poor Romanian skills, those with
cerebral co morbidities, with visual or auditory
impairment or with mental retardation were excluded
from the study.
Sex
Age
average

Brief Psychiatric Rating Scale, correlates negatively with

subjective quality of life subscales, but not with objective
ones. In addition, negative symptoms seem to have a
greater impact on subjective measures of quality of life.
Norman et al. (2) showed that both positive and negative
symptoms were related to the scores on the Quality of Life
Scale. Brown et al. (3) studied QoL in patients with
schizophrenia who were attending a rehabilitation centre
and learned that it is inversely related to negative
symptom severity. In an article from 2010, Gallupi,
Turola, Nanni, Mazzoni, and Grassi (4) showed that QoL
was negatively related to psychiatric symptoms.
A number of studies have pointed out a strong
relationship between QoL in schizophrenia and general
psychopathology measures, and moreover, that the
positive and negative symptoms are less related to the
quality of life. Huppert, Weiss, Lim, Pratt, and Smith (5)
found that higher anxiety ratings were associated with less
satisfaction with global quality of life, daily activities,
family, health and social relationship. No other symptoms
of schizophrenia were as strongly associated with
subjective quality of life. Hoffer, Kemmler, Eder,
Edlinger, Hummer, and Fleischhacker (6) indicated that
depression/anxiety component of the PANSS,
parkinsonism, and a negative attitude toward
antipsychotic medication negatively influenced the
patients' QOL, while cognitive symptoms and
employment status correlated with higher QoL. Saarni,
Vierti, Perl, Koskinen, Lnnqvist, and Suvisaari (7)
state that depressive symptoms are the strongest
predictors of poor QoL in psychotic disorders
(schizophrenia, bipolar disorders, other psychotic
disorders). Wilson-d'Almeida, Karrow, Bralet, Bazin,
Hardy-Bayle, and Falissard (8) demonstrated that a
decrease in symptoms in outpatients diagnosed with
schizophrenia was correlated to an increase in both
expectations and perceived position in life but did not
correlate to quality of life.
Although the outcomes of the studies above are
divergent in some degree, authors admit that QoL is a
multifaceted concept and the crucial role of the social,
psychological and cultural factors cannot be eluded. In a
cross-cultural comparison, Gaite et al. (9) indicated work,
finances, and safety as more independent from local
variations. Ritsner et al. concluded that psychosocial
factors rather than psychopathologic symptoms affect
subjective QOL of hospitalized patients with severe
mental disorders (10), while, in a qualitative research,
Gee, Pearce, and Jackson (11) identified ten domains with
impact on Qol: barriers placed on relationships; reduced
control of behaviors and actions; loss of opportunity to
fulfill occupational roles; financial constraints on
activities and plans; subjective experience of psychotic
symptoms; side effects and attitudes to medication;
psychological responses to living with schizophrenia;
labeling and attitudes from others; concerns for the future
and positive outcomes from experiences.
Beyond the theoretical interest that incongruence on
this topic arouses, pragmatic aspects as the need to
develop complex ways to assist the suffering person extra
muros, outside the walls of the hospital and outside the
walls of mental illness itself, determined the research
described in the following paragraphs.

36

distribut
ion
M

29

Education level

Marital status

Employment
status

31

Bachelors
degree

17

Married

Employee

High
school

29

Not
married

40

Retired

39

11

No
employmen
t

13

Vocational
school

14

Divorced

Table 1. Demographic characteristics of the participants

Instruments
Short Form-36 Questionnaire (SF-36)
SF-36 Questionnaire is a generic instrument designed
and tested by New England Medical Center in order to
assess the health status in a large number of medical
conditions. SF-36 is the short form of a 245 items
questionnaire developed within Medical Outcomes Study.
The questionnaire was proved to be useful in monitoring
patients with single or multiple pathological medical
conditions. As a meta-analytical study on this topic shows
(12), it is placed by many authors on a higher position than
other generic instruments used in the assessment of
quality of life in chronic illness. The instrument is a selfadministrated one and it consists in 36 items grouped in 8
scales: physical function (PF), physical role (PR), somatic
pain (SP), general health (GH), vitality (VT), social
function (SF), emotional role (ER), mental health (MH).
The 8 scales are subordinated to two generic concepts:
physical health (PF, PR, SP, GH) and mental health (VT,

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

SF, ER, MH).
The scale was translated and adapted in Romania due to
the International Quality of Life Assessment project
(IQOLA).
Positive and negative Syndrome Scale (PANSS)
Published in 1987 by Stanley Kay, Lewis Opler and
Abraham Fiszbein (13), PANSS became one of the most
used tools in studies regarding the antipsychotic
treatment.
As the name suggests, the scale is a medical scale that
measures the severity of the two types of symptoms found
in schizophrenia: the positive (delusions, conceptual
disorganization, hallucinations, hyperactivity,
grandiosity, suspiciousness/persecution, hostility) and the
negative ones (blunted affect, emotional withdrawal, poor
rapport, passive/apathetic social withdrawal, difficulty in
abstract thinking, lack of spontaneity and flow of
conversation, stereotyped thinking), to which is added a
general psychopathology scale (somatic concern, anxiety,
guilt feelings, tension, mannerisms and posturing,
depression, motor retardation, uncooperativeness,
unusual thought content, disorientation, poor attention,
lack of judgment and insight, disturbance of volition, poor
impulse control, preoccupation, active social avoidance).
In order to optimize the objectivity of the tool and to
assure valid data, a standardized interview used
previously to the scale completion was created: the SCIPANSS (Structured Clinical Interview for PANSS).
In Romania, the instrument was adapted under the
coordination of Simona tefan, Daniel David and Doina
Cosman.
Procedure
The participants were provided with verbal and written
information regarding the purpose and length of the
evaluation, confidentiality issues, and the possibility to

PANSS
positive
subscale

leave the study at any time. Afterwards, they were asked to

express their written consent to take part in the research.
Each participant took individually the standardized
SCI-PANSS interview and was instructed in self
administrating the SF-36.
The statistic processing of the collected data was done
using SPSS (Statistical Package for Social Science),
version 15.0 for Windows.
RESULTS
In order to check the hypothesis of a connection
between the quality of life and the severity of positive
symptoms in paranoid schizophrenia outpatients, the
score of the SF-36 specific scales, SF-36 generic scales
and PANSS positive subscale were correlated (in table 2).
There is no significant correlation between the SF-36
subscales and the PANSS positive subscale scores, which
means that the first hypothesis of the study is not
confirmed.
The hypothesis of a connection between the quality of
life and the severity of negative symptoms in paranoid
schizophrenia outpatients was verified by correlating the
score of the SF-36 specific and generic scales and PANSS
negative subscale (table 3).
Again, no significant correlation between the variables
was found, so we can conclude that the second hypothesis
of the study is not confirmed.
The third hypothesis, regarding a possible connection
between the quality of life and the severity of general
pathology in paranoid schizophrenia outpatients, was
tested by correlating the SF-36 scores with the PANSS
general psychopathology subscale scores. In order to
deepen the analysis, correlations were also made between
SF-36 subscales and each item of the PANSS general
psychopathology subscale (table 4).

PF

PR

SP

GH

VT

SF

ER

MH

Physical
health

Mental
health

.129

-.14

-.089

-.035

-.089

-.258

-.015

-.281

.048

-.254

*Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).
Table 2. The correlation between SF-36 specific scales (PF: physical function, PR: physical role, SP: somatic pain, GH: general health,
VT: vitality, SF: social function, ER: emotional role, MH: mental health), SF-36 generic scales (physical health, mental health) and
PANSS positive subscale

PANSS
negative
subscale

PF

PR

SP

GH

VT

SF

ER

MH

Physical
health

Mental health

.069

-.048

.236

.365*

-.033

.191

.084

.149

.152

.125

*Correlation is significant at the 0.05 level (2-tailed).

** Correlation is significant at the 0.01 level (2-tailed).
Table 3. The correlation between SF-36 specific scales (PF: physical function, PR: physical role, SP: somatic pain, GH:
general health, VT: vitality, SF: social function, ER: emotional role, MH: mental health), SF-36 generic scales (physical
health, mental health) and PANSS negative subscale

135

Anca L. Atudorei: Quality Of Life And Psychiatric Symptoms In Paranoid Schizophrenia

PANSS
general
psychopatology
subscale
G1
G2
G3
G4
G5
G6
G7
G8
G9
G10
G11
G12
G13
G14
G15
G16

PF

PR

SP

GH

VT

SF

ER

MH

Physic. health

Mental health

-0.07

-.198

-.263

-.17

-.402**

-.321*

-.082

-.432**

-.13

-.386*

-.242
.021
.023
.168
.004
-.247
-.099
-.091
-.016
.062
-.143
.105
-.101
.084
.308*
.088

.091
-.307*
-.158
-.018
-.075
-.111
-.059
-.066
-.199
-.004
-.213
.067
-.159
-.018
-.081
-.164

-.400**
.055
-.286
-.023
-.125
-.372*
-.002
-.035
-.304*
-.232
-.214
.114
-.069
-0.02
.069
.057

-.257
-.218
-.271
-.078
-.118
-.461**
.025
.06
-.255
-.078
-.267
.166
-.039
.015
.27
.076

-.23
-.247
-.323*
-.111
-.239
-.522**
-0.25
-.027
-.421**
-.053
-.376*
.01
-.342*
-.031
.032
-.096

-.049
-.22
-.401**
-.369*
-.014
-.370*
.168
-.076
-.399**
-.082
-.386*
-.048
-.096
-.224
.097
.103

.207
-.105
-.16
.031
-.036
-.175
.027
.039
-.165
-.053
-.159
.107
-.168
-.037
.147
.074

-.172
-.392**
-.441**
-.417**
-.149
-.421**
.038
-.127
-.442**
-.163
-.475**
-.046
-.178
-.195
.044
.071

-.324*
-.022
-.082
.173
-.072
-.298
-.094
-.036
-.129
-.024
-.152
.169
-.07
.105
.179
-.029

0
-.347*
-.444**
-.376*
-.133
-.415**
.049
-.055
-.454**
-.135
-.438**
-.038
.221
-.205
.052
.071

*Correlation is significant at the 0.05 level (2-tailed).

** Correlation is significant at the 0.01 level (2-tailed).
Table 4. The correlation between SF-36 specific scales (PF: physical function, PR: physical role, SP: somatic pain, GH: general health,
VT: vitality, SF: social function, ER: emotional role, MH: mental health), SF-36 generic scales (physical health, mental health) and
PANSS general psychopathology subscale (G1: somatic concern, G2: anxiety, G3: guilt feelings, G4: tension, G5: mannerisms and
posturing, G6: depression, G7: motor retardation, G8: uncooperativeness, G9: unusual thought content, G10: disorientation, G11: poor
attention, G12: lack of judgment and insight, G13: disturbance of volition, G14: poor impulse control, G15: preoccupation, G16: active
social avoidance)

First of all, we can identify a significant negative

correlation (p<.05) between the general mental health
subscale of SF-36 and PANSS general psychopathology
subscale. General mental health scale also correlates
negatively with anxiety (p<.05), guilt feelings (p<.01),
tension (p<.05), depression (p<.01), unusual thought
content (p<.01) and poor attention (p<.01).
Among the 8 specific subscales of SF-36, vitality and
mental health strongly correlates in a negative ratio with
the general psychopathology subscale (p<.01). There is
another negative correlation (p<.05) between social
functioning and PANSS general psychopathology
subscale.
Strong negative correlations (p<.01) were found
between: somatic pain and somatic concern, general
health and depression, vitality and depression, vitality and
unusual thought content, social function and guilt
feelings, social function and unusual thought content,
mental health and anxiety, mental health and guilt
feelings, mental health and tension, mental health and
depression, mental health and unusual thought content,
mental health and poor attention.
Mild negative correlations (p<.05) were found
between: physical role and anxiety, somatic pain and
depression, somatic pain and unusual thought content,
vitality and guilt feelings, vitality and poor attention,
vitality and disturbance of volition, social function and
tension, social function and depression, social function
and poor attention, physical health and somatic concern.
A positive correlation (p<.05) emerged between
physical function and preoccupation.
DISCUSSIONS
For the last two decades, the topic of QoL in
schizophrenia has been a subject of debate among
specialists, especially due to its important therapeutic
136

implications. Although a special interest was shown to the

relationship between QoL and psychiatric symptoms,
different measuring strategies, various study designs or
diverse approaches in defining QoL resulted in a number
of conclusions that are not always convergent.
In this study, QoL was not related to positive or
negative symptoms of paranoid schizophrenia, but there
was a negative connection between the self-reported
mental health and general pathology. Among the general
symptoms, depression, guilt feelings, unusual thought
content, poor attention, anxiety and tension correlated in a
negative ratio with QoL. We can infer that, for the
participants in this study, outpatients, in different degrees
of remission, the impact of specific schizophrenia
symptoms on the perceived QoL was rather weak.
According to these results, in a stable, compliant patient,
other variables are more likely to contribute to the sense of
well-being. Fitzgerald et al. (14) reported similar findings,
but, in their study, subjectively reported life satisfaction
correlated especially with depressive symptoms. The
results are consistent with Eack and Newhill's metaanalytical study which pointed out that weighted effect
size analyses revealed small relationships between
psychiatric symptoms and QoL, with general
psychopathology showing the strongest negative
associations across all QoL indicators (15).
Furthermore, as the results suggest, general symptoms
can have a negative impact on social functioning. Guilt
feelings, unusual thought content, tension, depression,
and poor attention can also have a negative impact on the
level of social functioning, while depression, unusual
thought content, guilt feelings, poor attention, disturbance
of volition can alter the person's vitality.
In addition, although pain is not in the foreground of
this chronic disorder, the results show that somatic issues
can interfere with variables like somatic concern,

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014

depression, anxiety, unusual thought content, and
preoccupation, demonstrating once again the need to
place QoL in relation to the bio-psycho-social triad
represented by each individual.
All these findings suggest that, beyond the specific
medical treatment, in a stable phase of the disease,
psychological and social factors must be addressed in
order to enhance the health of the person in sufferance.
This is why, in the author's opinion, the results can open
new perspectives to community psychiatry, psychology
and psychotherapy.
CONCLUSIONS
Pharmacotherapy in schizophrenia has come a long way
since the first neuroleptics, allowing the clinicians to
focus more and more on community-based care of people
with this type of mental illness. This paradigm shift
brought a greater concern towards the quality of life of the
suffering person, as the large number of studies on this
topic indicates.
The present research on psychiatric symptoms and
QoL in people with schizophrenia highlights the impact of
some nonspecific symptoms, like depression, guilt
feelings, unusual thought content, poor attention, anxiety
or tension, on the self-rated mental health. The same
factors also seem to connect with social functioning. More
permeable to psychotherapeutic intervention, these
variables could be integrated in complex therapeutic
strategies, together with the encouragement of increased
participation of families and communities in the
treatment.
The relatively small number of participants, slightly
uneven distribution by gender and level of education, the
transversal design, the use of a generic Qol questionnaire,
and the heterogeneous pharmacological treatment can be
pointed out as study limitations. However, in the author's
opinion, the results of the research can help to create a link
between the hospital-base care and the social integration
of the person diagnosed with paranoid schizophrenia.

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***

137

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a) Introduction (no more than 25% of the text), material and methods, results, comments or discussions and
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Instructions for authors

acknowledgements.
b) Material and methods have to be described in enough detail to permit reproduction by other teams. The
same product names should be used throughout the text (with the brand name in parenthesis at the first
use).
c) Results should be presented concisely. Tables and figures should not duplicate text.
d) The discussions should set the results in context and set forth the major conclusions of the authors.
Information from the Introduction or Results should not be repeated unless necessary for clarity. The
discussion should also include a comparison among the obtained results and other studies from the
literature, with explanations or hypothesis on the observed differences, comments on the importance of
the study and the actual status of the investigated subject, unsolved problems, questions to be answered
in the future.
e) In addition to the customary recognition of non-authors who have been helpful to the work described, the
acknowledgements section must disclose any substantive conflicts of interest.
f) Abbreviations shall be preceded by the full term at their first apparition in text. A list of all used
abbreviations shall be made at the end of the article.
g) Separate pages: tables, graphics, pictures and schemes will appear on separate pages.
References should be numbered consecutively in the order in which they are first mentioned in the text. Identify
references in text, tables, and legends by Arabic numerals in parentheses.
The reference list will include only the references cited in the text (identified by Arabic numerals in
parentheses, not in square brackets and not bold).
All authors should be listed when six or less; when seven or more, list only the first three and add 'et al'
(Ionescu I, Popescu I, Georegscu I et al).
The name of the Journals cited in the References should be abbreviated according to ISI Journal Title
Abbreviations.
Examples:
- Reference to a journal publication:
Vrati R, Matei VMI. The crisis centre in Romania. Eur J Psychiat 2002; 29:305-311.
Reynolds CF, Frank E, Perel JM et al. Treatment of consecutive episodes of major depression in the elderly. Am J
Psychiat 1994; 151(12):1740-3.
- Reference to a book:
Vrasti R. The crisis centre in psychiatry. Toronto, London: Academic Press, 1993, 26-52.
- Reference to a chapter in an edited book:
Schuckit MA. Alcohol-Related Disorders. In: Sadock BJ, Sadock VA, Ruiz P (eds). Comprehensive Textbook of
Psychiatry. Philadelphia: Lippincott Williams and Wilkins, 2009, 1268-1287.
The placement of the italics, punctuation and the general aspect of the text format must comply with the rules
mentioned above. This is a mandatory and eliminatory condition.
INSTRUCTIONS FOR MANUSCRIPTS SUBMITTED IN ELECTRONIC FORMAT
The text should be edited in Word for Windows.
1. Use as few formatting commands as possible:
- input your text continuously (without breaks);
- do not use different types of fonts to highlight your text;
- any word or phrase that you would like to emphasize should be indicated throughout the text by underlining;
- use only the Enter key to indicate the end of the end of paragraphs, headings, lists etc.;
- do not use the Space Bar to indicate paragraphs, but only the Tab key.
2. Charts and tables should be edited in Word or Excel. Please indicate in the text, the place of the table, specifying
its name.
3. You can scan photographs (using Photostyler, Adobe-Photoshop or any other compatible programs) and save
them as .tif or .jpg files. Please indicate in the text, the place of the photograph, specifying its name.
4. You may use a common compression program: ARJ, RAR or ZIP.
5. Make sure that the text file from CD and the print-out correspond exactly.
6. Make sure that there are no errors on your CD.
7. Make sure your CD is adequately packed.
8. Make sure your CD has no viruses.
VERY IMPORTANT: All manuscripts intended for publication will be subject to peer-review by a committee of
experts which assesses the scientific and statistical correctness of articles submitted. The committee receives the
manuscripts without knowing the authors' name and proposes possible changes, which will be transmitted to the authors by
the medium of Editorial Board. The authors have the obligation to oversee the text in English language with the help of a
professional translator.
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Romanian Journal of Psychiatry, vol. XV, No.4 2013

Address to send the manuscripts is:

REVISTA ROMN DE PSIHIATRIE
ASOCIAIA ROMN DE PSIHIATRIE I PSIHOTERAPIE
Prof. Dr. Dan PRELIPCEANU
Clinical Hospital of Psychiatry Prof. Dr. Alexandru Obregia
os. Berceni 10, sector 4, 041914 Bucureti
Tel./Fax: +40-21-334.84.06
E-mail: aliat@artelecom.net
Contact: Viorel Roman web editor
E-mail: aliat@artelecom.net
Tel. +40-21-334.84.06
www.e-psihiatrie.ro/revista - print edition
www.romjpsychiat.ro - online edition

141

Index Of Authors

142

ROMANIAN JOURNAL
OF PSYCHIATRY
CONTENTS
EDITOR-IN-CHIEF:
CO-EDITORS:

SPECIAL ARTICLES
& Somatic Co-Morbidities and Frailty in Patients with Mental Disorders 110
Mihai V. Zamfir, Anca I. Talaman, Gabriel I. Prada
REVIEW ARTICLES
&

Dimensional Personological Perspective on Suicidal Behaviour

Tudor Niretean, Aurel Niretean, Emese Lukacs, Dana Cmpan,
Istvan Zsolt Szasz
& Clinical Instruments for the Evaluation of Suicide Risk
An Overview
Ana-Maria Exergian

115

118

ORIGINAL ARTICLES
& Comparative Dimensional Approach of Personality Disorders
Through the Models of Big Five and Big Seven
Istvn Zs Szsz, Adrian I Horvath, Tudor Niretean, Anna M Tth

124

& Irritability and Personality Traits as Suicide Risk Factors in Depression 127
Ana-Maria Exergian, Liana Kobylinska, Maria Ladea
&

Quality of Life and Psychiatric Symptoms in Paranoid Schizophrenia 133

Anca L. Atudorei

INSTRUCTIONS FOR AUTHORS

138

INDEX OF AUTHORS

142

Romanian Journal of Psychiatry and Psychotherapy is recognized in Romanian National Council

for Scientific Research in Higher Education, starting with January 2010, at B+ category

Romanian Journal of Psychiatry and Psychotherapy is indexed in the international data base Index
Copernicus Journal Master List, starting with 2009.

Doctors subscribed to this journal receive 5 CME credits / year.

Scientific articles published in the journal are credited with 80 CME credits / article.

APR

Dan PRELIPCEANU
Drago MARINESCU
Aurel NIRETEAN

ASSOCIATE EDITORS:
Doina COZMAN
Liana DEHELEAN
Marieta GABO GRECU
Maria LADEA
Cristinel TEFNESCU
Ctlina TUDOSE
Executive editors: Elena CLINESCU
Valentin MATEI
STEERING COMMITTEE:
Vasile CHIRI (Honorary Member
of the Romanian Academy of
Medical Sciences, Iai)
Michael DAVIDSON (Professor, Sackler
School of Medicine Tel Aviv Univ.,
Mount Sinai School of Medicine,
New York)
Virgil ENTESCU (Member of the Romanian
Academy of Medical Sciences, Satu
Mare)
Ioana MICLUIA (UMF Cluj-Napoca)
erban IONESCU (Paris VIII Universiy, TroisRivieres University, Quebec)
Mircea LZRESCU (Honorary Member of the
Romanian Academy
of Medical Sciences, Timioara)
Juan E. MEZZICH (Professor of Psychiatry
and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
Sinai School of Medicine, New York
University)
Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Department of Psychiatry,
University of Maryland School of
Medicine, Baltimore)
Sorin RIGA (senior researcher)
Dan RUJESCU (Head of Psychiatric Genomics
and Neurobiology
and of Division of Molecular and
Clinical Neurobiology,
Department of Psychiatry, LudwigMaximilians-University, Munchen)
Eliot SOREL (George Washington University,
Washington DC)
Maria GRIGOROIU-ERBNESCU
(senior researcher)
Tudor UDRITOIU (UMF Craiova)

www.romjpsychiat.ro