COMITET DE REDACŢIE

Redactor şef: Dan PRELIPCEANU

Redactor-şefi
adjuncți: Dragoş MARINESCU
Aurel NIREŞTEAN
COLECTIV REDACŢIONAL
Doina COZMAN
Liana DEHELEAN

REVISTA
Marieta GABOŞ GRECU
Maria LADEA
Cristinel ŞTEFĂNESCU
Cătălina TUDOSE

Secretar de redacţie: Valentin MATEI

CONSILIU ŞTIINŢIFIC
Vasile CHIRIŢĂ (membru de onoare
al Academiei de Ştiinţe Medicale,
Iaşi)
Michael DAVIDSON (Professor, Sackler
School of Medicine Tel Aviv Univ.,
Mount Sinai School of Medicine,
ROMÂNĂ
New York)

de
Virgil ENĂTESCU (membru al Academiei de
Ştiinţe Medicale, Satu Mare)
Ioana MICLUŢIA (UMF Cluj-Napoca)
Şerban IONESCU (Universitatea
Paris VIII, Universitatea Trois-
Rivieres, Quebec)
Mircea LĂZĂRESCU (membru de onoare al
Academiei de Ştiinţe Medicale,
Timisoara)
Juan E. MEZZICH (Professor of Psychiatry
and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
Sinai School of Medicine, New York
PSIHIATRIE
University)
Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Department of Psychiatry,
University of Maryland School of
Medicine, Baltimore)
Sorin RIGA (cercetător principal gr.I)
Dan RUJESCU (Head of Psychiatric
Genomics and Neurobiology
and of Division of Molecular and
Clinical Neurobiology, Department
of Psychiatry, Ludwig- Maximilians-
University, Munchen)
Eliot SOREL (George Washington
University, Washington DC)
Maria GRIGOROIU-ŞERBĂNESCU
(cercetător principal gr.I)
Tudor UDRIŞTOIU (UMF Craiova)

ARPP ROMANIAN JOURNAL OF PSYCHIATRY

ASOCIAŢIA ROMÂNĂ Vol XX Nr. 1 May 2018

DE PSIHIATRIE ŞI PSIHOTERAPIE
QUARTERLY

www.romjpsychiat.ro CNCSIS B+ p-ISSN: 1454-7848 e-ISSN: 2068-7176

CUPRINS

REZUMATE A XI-A CONFERINȚĂ NAȚIONALĂ DE PSIHIATRIE SI PSIHOFARMACOLOGIE

CRAIOVA, 18-21 APRILIE 2018 1

ARTICOLE DE SINTEZĂ

& Evalurea obiectivă a Funcțiilor Executive la adulții cu autism și inteligență normală 19

Ilinca Mihailescu, Alina A. Frunză, Emanuela L. Andrei, Florina Rad, Iuliana Dobrescu, Mirela Manea

ARTICOLE ORIGINALE

& Opiniile rezidenților români în psihiatrie asupra factorilor care le influențează decizia de a
emigra ca o provocare pentru reformele din sistemul educațional și medical psihiatric 27
Adriana Mihai, Maria Silvia Trandafir, Lavinia Duică, Alex Mihai, Cosmin Lungu,
Anca Livia Chiriță, Mihail Cristian Pîrlog

& Temporizarea primului consult psihiatric în două clinici de pacienți acuți din România 31
Andreea R. Tirintică, Mihail C. Pîrlog, Dragoș O. Alexandru, Traian Purnichi, Biatrice Mihălcuț,
Mariana Dragomir, Laura Demijan, Aurel Nireștean, Adriana Mihai

& Corelații între răspunsul afectiv și nivelul de agresivitate la pacienții cu tulburări psihotice 35
Ionela N Cotos, Karol J Wild

CAZ CLINIC

& Creatină crescută la un pacient fără tratament antipsihotic 39

Ana-Anca Talașman, Mihaela Nae, Alexandra Dolfi

INSTRUCŢIUNI PENTRU AUTORI 42

Revista Română de Psihiatrie este indexată de Consiliul Naţional al Cercetării Ştiinţifice din
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Colegiul Medicilor din România acordă abonaţilor la această publicaţie 5 credite EMC/an.
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Revista Română de Psihiatrie este editată de Asociaţia Română de Psihiatrie şi Psihoterapie

şi Asociaţia Medicală Română
SPECIAL ARTICLES
TH
THE XI NATIONAL CONFERENCE OF
BIOLOGICAL PSYCHIATRY AND
PSYCHOPHARMACOLOGY CRAIOVA, APRIL 18-
21, 2018
Abstracts
ATYPICAL PSYCHOTIC ONSET OF DEMENTIA
Cătălina Tudose1, Raluca Tipa1, Alexander Strulovici2,
Lia Șchiopu2
1
University of Medicine and Pharmacy „Carol Davila”
Bucharest – Department of Psychiatry
2
Psychiatric Clinical Hospital „Prof. Dr. Alexandru
Obregia”, Bucharest, Romania
Worldwide, the number of elderly people is increasing and
the number of patients diagnosed with dementia has
reached 50 million people in 2017.
Dementia is one of the leading causes of disability and it
has a big impact both on families and healthcare services.
However, dementia affects each person in a different way,
depending on the impact of the disease, the person's
personality before becoming ill and individual life
circumstances. Due to this, the onset might be atypical and
the clinicians can face a difficult diagnosis. It is well
known the fact that the symptomatology of dementia
includes cognitive as well as non-cognitive symptoms
(BPSD – Behavioural and Psychological Symptoms of
Dementia), that can be present any time during the
evolution of the disease; usually psychotic symptoms
come out in the advanced stages of the illness. More than
that there are some types of dementia which associate
psychotic symptoms.
In this paper we want bring into your attention several
cases of dementia with atypical and severe psychotic
onset. We are presenting several cases aged over 65
diagnosed with psychotic disorders who were admitted as
emergencies in the hospital. Carefully assessment of the
psychotic symptomatology, continuous but soft
surveillance, small doses of medication (neuroleptics),
psychologically assessment regarding premorbid
personality and specific life circumstances, as well as the
neuro-psychological evaluation when it is possible
(decline of the psychopathological intensity of
symptoms). Concomitantly there were performed
interviews and periodically assessments of the families'
attitudes, level of knowledge and their capacity of
understanding and acceptance of a psychiatric diagnose.
Besides this, early diagnosis of dementia it is a must and
should not to be ignored.
In all the cases described above it was identified a mild or
medium cognitive decline which was hidden by the acute
psychotic symptomatology. Adequate treatment and
appropriate psychological interventions could put at ease
the disease evolution and could improve patients and
families' quality of life.
Keywords: dementia, psychotic, elderly, onset.
METHODS FOR EVALUATION OF THE QUALITY
OF LIFE DURING PHARMACOLOGICAL
TREATMENT IN YOUNG ADULTS DIAGNOSED
WITH SCHIZOPHRENIA
Octavian Vasiliu
Department of Psychiatry, University Emergency Central
Military Hospital “Dr. Carol Davila” Bucharest, Romania
Background: Pharmacological treatment is expected to
increase the quality of life in patients diagnosed with
schizophrenia, by reduction of their symptoms' severity
and by improving overall functionality. However, due to
several adverse events of antipsychotics, i.e. sedation or
weight gain, the perceived general health could remain
sub-optimal. A practical challenge is represented by
choosing the most appropriate psychometric tool for the
quality of life measurement.
Methods: A literature review was conducted and papers
published between 2000 and 2017 in main electronic
databases (PubMed, Cochrane, EMBASE, CINAHL)
were included. Keywords used for database search were
“quality of life”, combined with “scales”, “inventories”,
“questionnaires”, “schizophrenia”, and “young adults”.
Results: A number of 25 papers remained after the
application of inclusion/exclusion criteria. We selected
psychometric tools focused on quality of life in young
adults diagnosed with schizophrenia which included
domains related to work, financial and educational
domains. Quality of Life in Schizophrenia (QLiS)–short
version has 13 items distributed in 3 domains- social life
and finances, illness-related quality of life, and global
subjective well-being. Schizophrenia Quality of Life Scale
(SQLS)-30 item questionnaire is an easy-to-administer
instrument, evaluating psychosocial, motivation and
energy, symptoms and side effects. Lancashire Quality of
Life Profile (LQOLP) is a patient-rated scale with 15
scales integrating a number of 105 items.
Discussion: Structured evaluation of quality of life is
recommended in both research and clinical settings for
young adults diagnosed with schizophrenia. This variable
should be determined at baseline and during the
pharmacological treatment, in order to monitor its
efficacy.
Keywords: quality of life, schizophrenia, scales.
PROGRESSIVE SUPRANUCLEAR PALSY
Cornelia Zaharia, Valerica Tudorica, Laurențiu Ene,
Denisa Vasilica Pirscoveanu, Carmen Valeria Albu
University of Medicine and Pharmacy of Craiova,
Romania
1
The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
Progressive supranuclear palsy (PSP) or Steele-
Richardson-Olzewski is a neurologic disease named after
the supranuclear palsy that is a characteristic of the
disease. It is a rare affection, with a prevalence of 6
cases/100.000 persons and it has a severe prognosis. The
main cerebral regions that are affected are brainstem,
especially the midbrain, that is implicated in vertical
control of ocular muscles, basal ganglia, the dentate
nucleus of the cerebellum and cerebral cortex, especially
frontal lobe and spinal cord.
The initial manifestation of the disease can be a depressive
disorder. The patient seeks for medical attention for severe
balance disorder, that is responsible for falls. In evolution,
patients present speech disorders, swallowing is affected,
life expectancy rarely being over 15 years.
Keywords: progressive supranuclear palsy, depression,
life expectancy.
SUCCESSFUL REMISSIONS AND
P S Y C H O S O C I A L R E H A B I L I TAT I O N I N
PATIENTS WITH CHRONIC TREATMENT-
RESISTANT PSYCHOSES
Cătălina Tudose1, Nicoleta Popa2, Raluca Tipa1, Alexander
Strulovici2, Vanessa Maria Vlad2
1
University of Medicine and Pharmacy „Carol Davila”
Bucharest – Department of Psychiatry
2
Psychiatric Clinical Hospital „Prof. Dr. Alexandru
Obregia”, Bucharest, Romania
We bring to your attention some cases of chronic, resistant
to treatment psychoses, which, initially seemed to be
irrecoverable: patients had multiples hospitalizations in
many psychiatric hospitals, they were non-compliant to
psychotropic treatment, with low familial support and
with no jobs or other systematic activities.
All patients were aged from 28 to 38 years old and had
higher education or graduated high school. We also
identified some similarities in the personal and family
history: they have large families, but there were important
dysfunctionalities determined mainly by the very low
understanding of the disease, the shame and the stigma for
having a family member with a psychiatric disorder, lack
of support for the continuity of the antipsychotic treatment
by the denial of the disease; directly and indirectly the
families have influenced the patients negative attitude
toward the disease and its adequate treatment.
The management of these cases required:
§the involvement of an extensive and complex team of
specialists (doctors, residents, psychologists, nurses) in
order to assess, to council, to educate the patients and their
families;
§rigorously monitorization of the neuroleptic depot
medication by deeply involving the families;
§prolonged follow-up from 6 months to 5 years, until the
achievement of remission (some cases succeeded and
were remitted after 2-3 years of correct treatment with a
continuous, but slow improvement of the
symptomatology).
The monitorization service offered by the hospital proved
to be a good way to assist these kind of cases, taking into
account the lack of continuity of care in the actual
ambulatory system.
Noncompliace to antipsychotic treatment is a major
impediment in managing psychotic disorders. It is
2
essential to understand the causes of these attitudes and to
support continuously the patient and his/her family by all
means - in addition to the uninterrupted antipsychotic
depot medication, patients also need counseling, support,
education, psychotherapy, psycho-social interventions in
order to achieve a complete rehabilitation.
Keywords: chronic psychosis, antipsychotics, depot
treatment.
ACTUAL PATHOPHYSIOLOGIC THEORIES OF
SCHIZOPHRENIA AND NEW THERAPEUTIC
STRATEGIES
Lavinia Duică
“Lucian Blaga” University of Sibiu, Romania
“Dr. Gh. Preda” Psyhiatric Hospital of Sibiu, Romania
Dopaminergic theory is the first pathophysiologic model
of schizophrenia, which underlie conventional
antipsychotic medication. Interaction of dopamine and
other neurotransmitters (serotonin, glutamate, GABA)
added new significations to symptomatic polymorphism
of schizophrenia. At the same time, knowing these
interactions led to synthesis of conventional
antipsychotics, which are the first line of schizophrenia
treatment.
Actual antipsychotics are much efficient in treating
positive symptoms of schizophrenia and less efficient in
treating negative and cognitive symptoms. Thus, the
target of research in psychopharmacology is adjuvant
medication of actual antipsychotic drugs or independent
therapy in schizophrenia.
Creating pharmacologic agents which act at glutamate
receptors, inhibiting glycine transporters, or agonists of
M2/M3 muscarinic receptors, or nicotinic receptors, can
provide to these substances the capacity of treating
negative and cognitive symptoms of schizophrenia.
The cannabinoid system (antagonists of cannabinoid
receptors) or neuropeptide system (neurokinin 3 receptor
antagonists) which interact with other known
neurotransmitters systems.
Genetic and epigenetic therapies could be another target
of psychopharmacology, although new progresses in
pharmacogenomics, in psychiatry, in toxicology and
epigenetic drugs are needed.
Keywords: schizophrenia, antipsychotics, glycine,
cannabinoid system.
EXTRAPYRAMIDAL SYMPTOMS IN
SCHIZOPHRENIA – POTENTIAL MARKER FOR
THE NEURODEGENERATIVE COURSE
Tudor Udristoiu, Dragos Marinescu, Ileana Marinescu
University of Medicine and Pharmacy of Craiova,
Romania
Extrapyramidal symptoms (EPS) are either primary
(before antipsychotic treatment) or secondary.
Epidemiological studies have shown that primary EPS,
also mentioned as soft neurological symptoms, are present
in 50-60% of the patients with schizophrenia and are
correlated with peri-, intra- and postpartum vulnerability
factors. At least one third of patients with EPS also have
other soft neurological manifestations (pyramidal or
cerebellar), convulsive seizures, enuresis or deficits in

motor integration (dysphasia, dyslexia, dyscalculia).
Secondary EPS, as a consequence of antipsychotic
medication, include several nosological categories, based
on specific rating scales: acute dystonia (12-15%),
akathisia (23-28%), parkinsonism (33-45%) and tardive
dyskinesia (2-5%). The risk for secondary EPS increases
twice if antipsychotics are administered in patients with
primary EPS.
The reduction of dopamine level by excessive blocking of
D2 receptors is the main trigger of the pathogenic
mechanisms, while the relation with other mediators may
change the clinical picture. Persistent EPS are associated
with cognitive deficit, therapeutic resistance, prominent
negative symptoms, depression and aggression. The
presence of hyperprolactinemia is a secondary indicator
for potential neurodegenerative mechanisms. The
potential neurobiochemical marker is the increase of
homocysteine levels.
The identification of primary EPS and the use of atypical
antipsychotics may reduce the risk for the activation of
neurodegenerative mechanisms.
Keywords: extrapyramidal symptoms,
neurodevelopmental abnormalities, hyperprolactinemia.
CLINICAL AND NEUROPHYSIOLOGICAL
CORRELATIONS OF FIRING AND KINDLING
PHENOMENA IN MAJOR PSYCHIATRIC
DISORDERS
Stefan Badescu, Ileana Marinescu, George Badescu
University of Medicine and Pharmacy of Craiova,
Romania
Connections between the hippocampus, amygdala, septal
nuclei, nucleus accumbens form the mesolimbic system
involved in biochemical theories of etiology in
schizophrenia. The plasticity of the NMDA (N-methyl-D-
asparate) receptor with hyper or hypofunction is relevant
in the models of kindling in epilepsy but also in
schizophrenia-like syndromes (Kraus, 2000). In
schizophrenia, "genetic defect" is demonstrated for
NMDH receptors, leading to cortico-striatal
hypoglutamatergia.
Aberrant discharges at the hippocampus level (“firing”)
increase the sensitivity to negative unwanted external
events, resulting in neurotransmission changes with bio-
chemical substrate. It is even supported by a ”prekindling”
of genetic risk factors for mental illness (Keneth S.
Kendler apr 2000). Thus, the genetic risk increases the rate
of the kindling phenomenon, being, alongside with the
external stresses, predictive factors of major depressive
episode
Currently, many researchers believe that the kindling
phenomenon is responsible for the rapid cycle and
resistance to treatment of bipolar disorder as well as being
involved in schizophrenia. Within the phenomenon, the
cycle starts with affective impulses, stressful, and exciting
events, which later become spontaneous.
The effects of kindling correlated with stress are an
additional motivation for the therapeutic support of
timostabilizers.
Antipsychotics are essential treatments for patients
diagnosed with psychotic disorders.
The use of atypical neuroleptics, reduces metabolism in
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
the frontal cortex, thus reducing the mechanism of "firing"
and psychotic manifestations.
Conventional neuroleptics are placed at the opposite pole,
activating the "gating" and "firing" mechanisms.
Keywords: firing, kindling, gating, psychosis,
antipsychotics.
AFFECTIVE DISORDERS IN AN INPATIENT
SETTING
Victor Gheorman1, Anca-Livia Chiriță1,2, Felicia
Militaru1,2, Silvia Ristea2,3, Daniela Glăvan1,2, Ion
Udriștoiu1,2, Mihail-Cristian Pîrlog1,2
1
University of Medicine and Pharmacy of Craiova,
Faculty of Medicine, Romania
2
Clinical Hospital of Neuropsychiatry Craiova, Romania
3
University of Medicine and Pharmacy of Craiova,
Doctoral School, Romania
Introduction: Affective disorders represent a large
nosological field important by frequency as clinical
severity. The depression and the bipolar disease produce
biological, psychological, social and economic
deficiency. The evolution of this disorders is unpredictable
with many relapses and schort remission period. Dates
from literature suggest that therapeutic efficiency is invers
proportional with the number and the time of the episodes.
Methods: We proposed to evaluate the distribution of
affective disorders in an inpatient setting (Psychiatry I
Department of Craiova), for a 4 years period (January 1st,
2013 – December 31st, 2016), by socio-demographic and
hospitalization parameter.
Results: In the period we did our research we can see that
from the total of 7045 admissions in Psychiatry
Department I of Craiova, the group of diagnostic of
affective disorders occupied more than 2/3 of the cases -
4523 admissions (64.20%), with a quite constant
evolution in time (60.04% in 2013, 67.34% in 2014,
67.24% in 2015, 62.99% in 2016). By gender distribution,
if in the case of admissions, the rate was 1.03 for the
women, for affective disorders the number of admissions
was 2661 women vs 1862 men, meaning a rate of 1.43. An
analyze by age, showed that affective disorders presented
high values for 55-64 interval of age (2174 admissions),
45-54 years old (1856 admissions) and 35-44 (241
admissions). The results referring at hospitalization days,
as an economic marker of medical services, we can see an
average 11 hospitalization days, quite constant for the
period of research.
Conclusions: The results show the impact that affective
disorders have not only over the patient (from medical and
socio-professional point of view), but also over medical
activity developed in the hospital. We think that all these
measures will improve the prognostic of the disease and it
also will improve the quality of patient's life.
Keywords: affective disorders, quality of life, hospital.
FUNCTIONAL IMPAIRMENT IN PERSONS
WITH ALCOHOL RELATED DISORDERS
Maria-Gabriela Puiu1, Mihnea Costin Manea2, Oanea
Manea3, Dan Costin Văireanu4, Ioana Anca Pacearcă5,
Mirela Manea6
1
Senior Psychiatrist, PhD, Lecturer “Carol Davila”
University of Medicine and Pharmacy, Faculty of Dental
Medicine, Bucharest
3
The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
2
MD, PhD, Lecturer “Carol Davila” University of
Medicine and Pharmacy, Faculty of Dental Medicine,
Bucharest
3
MD, PhD student, CF2 Clinical Hospital, Bucharest
4
DMD, Dentismart, Bucharest
5
MD, PhD student, Assistant Lecturer “Carol Davila”
University of Medicine and Pharmacy, Faculty of Dental
Medicine, Bucharest
6
Senior Psychiatrist, PhD, University Professor “Carol
Davila” University of Medicine and Pharmacy, Faculty of
Dental Medicine, Bucharest
Rationale: The alcohol has always been an important
subject of debate in relation to public health, worldwide.
In Romania alcohol represents the third major cause of
death in population due to associated diseases, traffic
accidents or workplace accidents. Beside psychiatric and
medical problems alcohol consumption is often
associated with marital difficulties, low efficiency and
absenteeism at workplace, delinquency and troubles in
social integration.
Objective of this cross- sectional study is to assess
functional impairment in work, social and family life in
persons admitted in “Alexandru Obregia” Clinical
Hospital of Psychiatry for alcohol related disorders.
Methods and Results: A number of 50 subjects admitted in
“Alexandru Obregia” Clinical Hospital of Psychiatry
were included in the study after consenting to participate.
Besides collecting a number of socio- demographic and
medical information, the subjects were asked to complete
Sheehan disability scale a brief, patient rated, measure of
disability and impairment. Results showed that prior to
hospital admission the subjects have had an important
impairment in work capacity having at least one day lost.
For most subjects in this study alcohol related problems
led to a negative impact on social and family life prior to
hospital admission.
Discussion: Hospital admissions for alcohol related
disorders are made when the negative impact on work,
social and family life is already present at an important
level. If efficient interventions are not provided for this
type of subjects, their difficulties in work, social and
family life will most likely increase, leading to a rapid
decrease in their quality of life.
Keywords: alcohol, quality of life, Sheehan disability
scale.
NEURODEGENERATIVE DISEASES – THE NEED
FOR A MODERN MANAGEMENT
Cătălina Tudose
University of Medicine and Pharmacy ”Carol Davila”
Bucharest, Romania
In the actual context of aging populations,
neurodegenerative diseases, and especially Alzheimer's
disease, became an important topic not only for
psychiatry, but also for public health, social assistance,
policy makers, and community as a whole.
The increasing rates of incidence and prevalence of these
disorders are leading to a need of a modern and complex
management of them, in which not only gaps in the
psychopharmacological treatments represent targets, but
also the way in which persons affected need to receive
assistance.
4
According to latest data from literature and
recommendations of the international forums, in the
present time it became obligatory to offer to individuals
diagnosed with neurodegenerative diseases an integrative
support which has to cover biological and therapeutically
areas, psychological and cognitive domains, and
respectively social and economical aspects of daily living.
Keywords: neurodegenerative disease, complex
management, multidisciplinary approach.
E T I O PAT O G E N E T I C S A N D C L I N I C A L -
THERAPEUTICAL ACTUALITIES IN
PSICHOCUTANEOUS DISEASES
Virgil-Radu Enatescu1, Marco Muntean2, Simona
Andronic2, Doru Mateeș2, Arthur Moraru2, Lavinia
Pantelimon2, Claudia Suru2
1
“Victor Babeș” University of Medicine and Pharmacy
Timișoara – Discipline of Psychiatry
2
“Eduard Pamfil” Psychiatric Clinic Timișoara, Romania
The comorbidity of dermatological disorders with
psychiatric disorders has been and continues to be an
important subject of psychosomatic research. Disorders
such as psoriasis, urticaria, angioedema, atopic dermatitis,
hyperhidrosis, acne and oral planar lichen are
significantly correlated with the presence of
psychopathological factors such as anxiety and
depression. It is often difficult to specify the temporal
sequence of occurrence of the two types of psychiatric and
dermatological disorders respectively. However, there is a
bidirectional determinism in the sense that, on the one
hand, diseases such as psoriasis or hyperhidrosis can lead
to social isolation of these patients with a strong negative
impact on self-esteem and with the resulting
consequences. On the other hand, it is possible that certain
dermatological conditions are nothing but one of the
multiple faces of psychiatric illness. Recent research,
based on immunological studies, has shown that both
psychiatric disorders as well as some dermatological
disorders are based on similar dysfunctions of the immune
system. Last but not least, the iatrogenic perspective of
this increased comorbidity must be considered. Thus,
synthetic corticosteroids used in dermatology can induce
or promote psychiatric symptoms such as depression, and
some psychotropic drugs used to treat mental illness
associate a considerable allergen potential. This paper
presents an extensive synthesis of the literature that
contains recent psychodermatology information.
Keywords: translational psychiatry, multimodal
mechanism of depression, corticosteroids.
PATIENT AND PHYSICIAN PERCEPTIONS OF
TREATMENT EMERGENT SIDE EFFECTS FROM
ANTIPSYCHOTIC THERAPY
Marco Muntean1, Simona Andronic1, Doru Mateeș1,
Arthur Moraru1, Lavinia Pantelimon1, Claudia Suru1,
Virgil-Radu Enatescu2
1
“Eduard Pamfil” Psychiatric Clinic Timișoara, Romania
2
“Victor Babeș” University of Medicine and Pharmacy
Timișoara – Discipline of Psychiatry
Background: Psychotic disorders represent a part of the
psychopathological spectrum in which the collection of
information related to the treatment emergent adverse

events (TEAE) with antipsychotics is impeded through
the temporary disturbance of the patient's perception and
general understanding.
Objectives: To describe the perceived intensity and
tolerability of TEAEs related to antipsychotic treatment
with the scope of creating a balance between the
physician's objectivity and the patient's subjectivity.
Methods: This is a qualitative, cross-sectional study
performed in a single clinical center. The TEAE variables
were measured by the Liverpool University Neuroleptic
Side Effect Rating Scale (LUNSERS) and Udvalg for
Kliniske Undersogelser Side Effect Rating Scale (UKU-
SERS), and insight was measured using the Birchwood
Insight Scale (BIS). The assessment scales were first
conceptualized in English and were faithfully translated
using a methodology adapted from the EPSILON Study 2.
Keywords: subjective perception vs. objective analysis,
statistic evidence, psychiatric emergency.
NEW THERAPEUTICAL MEANS FOR
SCHIZOPHRENIA – FOCUS ON THE DEEP BRAIN
STIMULATION
Octavian Vasiliu, Daniel Vasile, Andreea F. Alboae,
Mihaela C. Patrascu, Elena A. Morariu, Raluca
Manolache, Iulia Alexandru, Alin M. Badic
Department of Psychiatry, University Emergency Central
Military Hospital ”Dr. Carol Davila” Bucharest, Romania
Background: Deep brain stimulation (DBS) is an invasive
method used for refractory cases of obsessive-compulsive
disorders, treatment-resistant major depression, and
psychotic disorders. This therapeutic method is applied in
schizophrenia only as an experimental procedure, because
the number of studies regarding this indication is still very
limited.
Methods: A literature research was conducted using as
keywords “deep brain stimulation”, “schizophrenia”,
“psychotic disorders”, and “neural network
interventions”, and included papers published between
2000 and 2017 in main electronic databases (PubMed,
Cochrane, EMBASE, CINAHL). A number of 89 papers
surfaced, but after filtering the results, only 3
communications were retained (case reports), because
they included original clinical research on patients with
schizophrenia.
Results: A patient with treatment-resistant and severely
incapacitating schizophrenia received unilateral, left DBS
and presented positive response after 11 months (reflected
in Positive and Negative Syndrome Schizophrenia
scores), although she didn't respond to bilateral DBS.
Another patient received unilateral DBS in the right
nucleus accumbens for severely disabling and treatment-
resistant obsessive-compulsive disorder registered an
improvement of the core symptoms (reflected in Yale-
Brown Obsessive-Compulsive Scale scores). Yet another
patient diagnosed with schizophrenia presented severe
drug-induced tardive dyskinesia received right DBS and
left thalamotomy and dyskinesia disappeared completely,
confirmed at 41-month follow-up.
Discussion: Although the mechanism of action of DBS is
mostly unknown, this therapeutic method seems to be
useful for treatment-resistant cases of schizophrenia and
tardive dyskinesia.
Keywords: schizophrenia, deep brain stimulation,
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
therapeutic resistance.
HIGH CREATINE KINASE IN A PSYCHIATRIC
PAT I E N T W I T H O U T N E U R O L E P T I C
TREATMENT
Ana-Anca Talașman, Alexandra Dolfi, Dan Prelipceanu
Clinical Hospital of Psychiatry “Prof. Dr. Al. Obregia”
Bucharest, Romania
In psychiatry, high creatine kinase (CK) levels and
leukocytosis are known to be associated with neuroleptic
malignant syndrome (NMS), (1,2) but there are many
other causes that can present with an elevated serum level
of this enzyme. CK is affected by age, gender, race, but
also by many other diseases such as myocardial infarction
(elevated CK-MB fraction), neuromuscular diseases,
periodic paralyses, muscular traumas and high physical
effort, elevated CK being a sign of rhabdomyolysis. We
present a case of a 34-year- old male with spastic
tetraplegia, mental retardation and alcohol dependence
admitted in ”Alexandru Obregia” psychiatry hospital in
Bucharest, who presented a very elevated CK level (over
28000 units) at admission although no neuroleptic
treatment was administered.
Keywords: elevated creatine kinase, spastic tetraplegia,
alcoholism.
NEUROBIOLOGICAL FACTORS INVOLVED IN
NICOTINE ADDICTION IN SCHIZOPHRENIA
Lavinia Duică
“Lucian Blaga” University of Sibiu, Romania
“Dr. Gh. Preda” Psyhiatric Hospital of Sibiu, Romania
The increased prevalence of smoking in schizophrenia is
based on a number of factors related to the nicotine
addictive aspect as well as to the pathophysiology of
schizophrenia (genetic vulnerability, different clinical
aspects of the disease, etc.).
While smoking, nicotinic receptors are activated, and they
modulate several mediation systems (dopamine,
glutamate, serotonin) that are involved in achieving the
individual's pleasure or relaxation.
The genetic vulnerability of patients with schizophrenia as
regards nicotine addiction is related to the polymorphism
of the 5HTNA7 gene of nicotinic receptors which results
in their decrease in hippocampal density and sensory
selection dysfunction.
Because the metabolism of antipsychotics is interfering
with smoking in patients with schizophrenia, their efficacy
decreases and positive symptoms remain in these patients.
Positive symptoms induce a state of restlessness and
discomfort that will be ameliorated by increased smoking.
Another important aspect of the nicotine addiction of these
patients lies in its stimulating effect, which
counterbalances with the negative and cognitive
symptoms present in all stages of the disease, regardless of
whether or not the symptoms of the active phase are
present.
Keywords: schizophrenia, nicotine, addiction.
IMPULSE CONTROL DISORDERS IN
PARKINSON DISEASE
Oana Gâlceavă1, Diana Stanca1, Valerica Tudorică1,
Adrian Mită2, Roxana Lătea3, Ligia Giurgiulescu2, Victor
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The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
Gheorman5, Dan-Ionuț Gheonea4
1
Clinic of Neurology, University Of Medicine and
Pharmacy of Craiova, Romania
2
2nd Medical Department, University of Medicine and
Pharmacy of Craiova, Romania
3
Clinic Of Neurology, Clinical Neuropsychiatry Hospital,
Craiova, Romania
4
Research Center of Gastroenterology and Hepatology,
University of Medicine and Pharmacy of Craiova,
Romania
5
Psychiatry Clinic, Clinical Neuropsychiatry Hospital,
Craiova, Romania
Introduction: Impulse control disorders (ICDs) are
behavioral disturbances in which a person fails to resist
the drive to behave in ways that result in distress or
impaired social and occupational functioning. In
Parkinson's disease (PD), ICDs most commonly include
pathological gambling, excessive spending and
hypersexuality
Objective: The aim of our study was to evaluate the
presence of ICD in patients with Parkinson's disease
treated with dopamine agonists.
Material and methods: 48 patients (26 men and 22
women) with idiopathic Parkinson's disease were
included in our study. All the patients fulfilled the new
diagnostic criteria for Parkinson's disease. The lot of
patients was divided in two group: group A composed of
25 patients (mean age 66,2 years) which had in medication
dopamine agonist and group B, composed of 23 patients
(mean age 63,8 years) without dopamine agonist. All the
patients were evaluated with Impulse Control Disorders
and Related Condition Questionnaire (ICDRC).
Results and Conclusion: We observed a significantly
statistic difference when compared group A with group B,
on impulse control disorder, especially excessive
spending, hypersexuality and, less common, gambling.
Also, group A, had, more frequent, dopamine
dysregulation syndrome.
Keywords: Parkinson disease, impulse control disorders.
STUDY ON DEPRESSION IN PATIENTS WITH
PARKINSON DISEASE
Alexandra Stefania Balan1, Laurențiu Ene1, Rodion
Rotaru2, Cornelia Zaharia1, Valerica Tudorica1, Florin
Trifan1, Diana Stanca1, Valeria Carmen Albu1, Denisa
Vasilica Pirscoveanu1
1
University of Medicine and Pharmacy of Craiova,
Romania
2
Clinical Hospital of Neuropsyhiatry, Craiova, Romania
Depression is frequently associated with idiopathic
Parkinson disease., but real incidence and prevalence
differs between authors.
Objective: depressive status analysis in Parkinson patients
according to age, sex, environmental origin and disease
stage.
Patients and method: We included in our study group 65
patients aged between 45 and 75 years. Patients were
followed for a year. For depression status evaluation we
used Hamilton Rating Scale for Depression. We used a
control group of 72 persons. We evaluated patients at the
beginning of the study, at 6 months and 1 year.
6
Results and conclusion: Compared with control group,
Parkinson patients have a pronounced depressive status,
with no statistical differences according to sex,
environmental origin. Depression status is accentuated in
advanced stages.
Keywords: Parkinson disease, depression, disease stage.
STUDY ON ANXIETY IN PARKINSON DISEASE
Alina Păun2, Cornelia Zaharia1, Oana Alexandru1, Valerica
Tudorică1, Octavian Păun2, Laurențiu Ene1
1
University of Medicine and Pharmacy of Craiova,
Romania
2
Psychiatric Hospital “Prof Doctor Alexandru Obregia”,
Bucharest, Romania
Objective: we wanted to study the incidence of anxiety in
patients with idiopathic Parkinson disease.
Patients and method: we studied 30 patients hospitalized
in Craiova's Clinic Neuropsychiatry Hospital between
January 2016 and February 2017. Our group consisted of
16 men and 14 women, with median age of 64 years, our
patients being between 49 and 79 years old. We used
Zung-SAS scale (The Self–Rating Anxiety Scale of
Zung). We have made correlations between data obtained
using this scale and patient's age, years of disease, disease
stage, clinical form, motor or non-motor complications
and treatment.
Results and conclusions: we found anxiety in 63,3 % of
cases without differences according to sex, but the
incidence increased with age. Anxiety is also increased by
disease duration and stage of the disease.
Keywords: Parkinson disease, anxiety, stage of the
disease.
CT AND MRI IN NEURODEGENERATIVE
DISEASES
Roxana Mihaela Folcuți1, Dan Gheorghe Mălăescu2,
Dragoș Marinescu3
1
Titu Maiorescu University, Department of Radiology,
Bucharest, Romania
2
Titu Maiorescu” University, Department of
Morphopathology, Bucharest, Romania.
3
University of Medicine and Pharmacy of Craiova,
Department of Psychiatry, Craiova, Romania.
Neurodegenerative diseases represent a group of diseases
characterized by the multifocal or global alter of the
neuronal population. This group of diseases does not
produce clinical or morphological changes unless they
reach advanced stages, therefore there is an accentuate
need in early imaging diagnosis.
Computed tomography and Magnetic Resonance Imaging
are the most common neuroimaging techniques used in
present days. PET-CT or SPECT has a low sensibility and
specificity therefore they possess a limited role in the
diagnosis of neurodegenerative diseases. CT scan is
mainly used with the purpose of exclusion of treatable
conditions or to detect neurosurgical treatable patients
with cerebral metastases, chronic subdural hematomas,
normal pressure hydrocephaly and intra- or extra-axial
brain tumors. CT scans is able to provide important pieces
of information in severe forms of cerebral atrophy or no
apparent imaging changes in progressive forms of neurons

degeneration. In advanced stages of neurodegenerative
diseases CT shows localized or generalized cerebral
atrophy and the subsequent enlargement of the ventricular
system or subarachnoid spaces. MRI permits a more
specific evaluation than CT scan due to its superior
sensitivity to brain parenchymal changes. There are
differences in neurodegenerative MRI protocols
depending mainly upon local equipment and preferences.
However, it is essential to obtain a three-plane imaging
with the coronal images angled at right angles to the
hippocampus.
The imaging findings in neurodegenerative diseases are
non-specific and not strongly indicative of a certain entity.
Keywords: neurodegenerative, computed tomography,
magnetic resonance imaging.
ASSESSMENT OF COGNITIVE STATUS IN
PATIENTS WITH PARKINSON'S DISEASE
TREATED WITH NEUROTROPHIC FACTORS
Denisa Floriana Vasilica Pîrşcoveanu1, Valerica Tudorică1,
Ileana Marinescu2, Puiu Olivian Stovicek3
1
University of Medicine and Pharmacy of Craiova,
Department of Neurology, Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Department of Psychiatry, Craiova, Romania
3
Ti t u M a i o r e s c u U n i v e r s i t y, D e p a r t m e n t o f
Pharmacology, Bucharest, Romania
Objective: The aim of the study was to evaluate the
influence of the treatment with neurotrophic factors in the
patients with Parkinson's disease.
Material and methods: We studied 20 patients (10 men and
10 women) admitted in the Clinic of Neurology-
Neuropsychiatry Hospital Craiova during the year 2016
who met the inclusion criteria: age between 60 and 70
years, at least 9 years of education, established diagnosis
of Parkinson's disease in stage one or two on Hoehn-Yahr
Scale, and 4.5 years duration of the disease. The patients
received treatment with L-Dopa 600-800 mg/day (10
patients), L-Dopa 400 mg/day associated with dopamine
agonists (5 patients) and only dopamine agonists (5
patients). In addition to this treatment they received
Cerebrolysin 10 ml/day, 10 days/month for 6 months. At
baseline we evaluated the cognitive performances by
Mini-Mental State Examination (MMSE) and The Clock
Test. We reevaluated the patients after 3 months and at the
end of the study (after 6 months). The results were
analyzed by Student Test.
Results: At baseline the patients obtained a mean score of
28.7 at MMSE and 9.2 at The Clock Test. After six months
the results were better (29.2 at MMSE and 9.4 at The
Clock Test) but not significantly statistic.
Conclusions: We consider that the study must go on
because we need to evaluate much more patients for a
relevant conclusion.
Keywords: Parkinson's disease, cognitive performances.
THE IMPORTANCE OF KNOWLEDGE OF
DESIGNER DRUGS IN ADDICTION.
Iosif Gabos Grecu1,2, Marieta Gabos Grecu1,2, Róbert-
László Kiss2, Norbert Duma1
1
University of Medicine and Pharmacy of Târgu-Mureș,
Romania
2 element of the disorder (biological, psychological, social)
Department of Psychiatry I-Acutes, Clinical Hospital of
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
Mureș County, Târgu- Mureș, Romania
The legal drugs also known as designer or synthetic drugs
represent a serious threat to our society. Multiple
researches focus on investigating the effects of designer
drugs on the human body. The structure of these drugs is
similar to illegal drugs, with the very fact that they are
modified, until they can be commercialized legally, such
as bath salts, incenses and fragrances. These drugs
frequently have unknown mechanism of action,
unpredictable effects and side effects, often not even their
creators and distributors know the exact composition of
the respective drug. The widespreadness of these drugs
can be explained by the quick and easy access and
relatively cheap price. The objective of this study is to
measure the awareness on designer drugs and to determine
the most effective ways of prevention.
Methods: data collection was realized with an open-access
online, anonymous, questionnaire available on social
network. Results: more than half of the correspondents
were aware of the designer drugs and almost half of them
was able to give examples like mefedron, spice, K2.
According to the correspondents, the influence of friends
is the most relevant factor behind the consumption of
designer drugs. Internet is currently the most common
source of information, also it is considered that
educational system would be the proper place to increase
prevention and awareness.
Conclusion: The rapid emergence of synthetic drugs
creates new challenges for health care providers due to low
price, difficulty to identify the composition, toxicity and
adverse effects. A thorough knowledge of the available
designer drugs, common signs and symptoms of toxicity
of these agents, and potential treatment modalities are
fundamental to manage these patients.
Keywords: designer drugs, drug addicts, drugs of abuse.
SOCIAL IMPAIRMENT IN MENTAL HEALTH
DISORDERS
Mihail Cristian Pîrlog
University of Medicine and Pharmacy of Craiova,
Romania
Social vulnerability of people affected by mental health
disorders could be not just an effect, but also a trigger or a
favorable condition for the onset of the disease. Previous
psychological, genetical, neurobiological, and
neuroimaging studies had identified the role of
environmental factors during both the prodromal period
and evolution of any mental health disorder, all of them
having as outcome an important impairment of the social
role of the patients.
The social impairment of the persons diagnosed with
mental health disorders is present not only in the field of
maintaining social relationships, but also in its capacity to
cope with the symptoms, to have an independent life and a
good social-economical status. Moreover, social
impairment lead to an increasing burden of disease, both
for subject, but also for its family and community, burden
translated often in big financial costs.
Thus, social impairment represents an important target for
any therapeutically strategy, becoming necessary a
multilayer and multidisciplinary approach in which any
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The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
needs to be solved in order to ensure a good remission and
recovery of the individuals affected.
Keywords: social impairment, burden of disease, social
role, multidisciplinary approach.
INTERFERENCE OF ALCOHOLISM WITH
DEPRESSION
Elena Elisabeta Efrem1, Eliza Elena Petre1, Anca Livia
Chiriță2
1
Clinical Hospital of Neuropsychiatry, Department of
Psychiatry I, Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Department of Psychiatry, Romania
Disorders caused by excessive alcohol consumption
represents a challenge for the clinician, as statistics show
that in more than half of these cases, they are accompanied
by other psychiatric syndromes.
According to the latest World Health Organization
statistics, Romania is among the top 5 countries in terms of
alcohol consumption per capita. Among the most common
psychiatric comorbidities of alcohol-related disorders are
major depressive disorder and anxiety disorders.
Although approximately 40% of alcohol-dependent
patients experience periods of mood decline and
associated symptoms that meet the diagnostic criteria for
depression the percentages drop in case of abusive alcohol
consumption. The variable pattern of the evolution of the
alcohol-consuming patient makes it difficult to diagnose a
depressive disorder syndrome as well as the optimal
therapeutic intervention.
We will present the case of the I.M., patient aged 61, who
came to the Acute Psychiatric Service, presenting the
onset of the current episode by: depressed mood,
anhedonia, irritability, memory impairment, low yield,
insomnia. From the psychiatric history, we obtain data on
three other previous admissions, as well as the treatment
followed. From family data, we discover daily alcohol
consumption about 7 days before admission. We will
evaluate the extent to which alcohol consumption
influences the persistence of depressive symptomatology,
the primary or secondary character of depression, the
therapeutic possibilities imposed by the frequent
existence of somatic sufferings of alcohol addicts, and the
difficulty of compliance to treatment of these patients.
The medical, social and economic consequences of
alcohol consumption on the development of a recurrent
depressive disorder are multiple, including auto- or
heteroagresive risk, treatment compliance, and the profile
of adverse effects of antidepressant therapy.
There are multiple interferences between the two
disorders, case management depending on the way of
onset, the conditions in which the two diseases self-
sustain, requiring integrated assessment and treatment.
Keywords: depression, addiction, alcohol.
ANTICONVULSANTS DRUGS IN PSYCHIATRIC
DISORDER
Grațiela Olteanu1, Lavinia Duică2
1
„Dr. Gh. Preda” Psychiatric Hospital of Sibiu, Romania
2
„Lucian Blaga” University, „Dr. Gh. Preda” Psychiatric
Hospital of Sibiu, Romania
8
The capacity of the antiepileptic drugs to adjust the
neuronal electrical activity, hyperexcitability, membrane
depolarization, propagation of neuronal activity,
simultaneously, along different pathways, led to the use of
these drugs in multiple pathological fields.
Relationship between pathophysiological mechanisms
involved in initiating and maintaining a disease and the
role of drugs on changing specific activity in pathological
cells was the key of starting using antiepileptic drugs in
psychiatry.
Considering molecular targets for antiepileptic drugs,
there are the following classes: inhibitors of voltage-
sensitive sodium channels, which act especially on
neurons with high-frequency discharges; drugs which
boost the actions of neurotransmitter GABA; inhibitors of
T-type calcium channels, which adjust activity of thalamic
relay and reticular neurons; anticonvulsants with complex
mechanism of action- which blockade voltage-dependent
sodium and calcium channels, cause enhancement of
GABA and diminish glutamate levels; carbonic anhydrase
inhibitors- involve pH changes in the brain and,
consequently, modulation of glutamate receptors (pH
sensitive).
Resemblance between both, neurological and psychiatric
pathophysiological mechanisms caused the use of
antiepileptic drugs in psychiatry, especially as mood
stabilizer, treating bipolar disorder, acute manic and
mixed episodes, major depressive disorder, cluster B
personality disorders, drug use disorders, schizophrenia.
Elucidation of anticonvulsants mechanisms of action has
been challenging because agents may have multiple
mechanism of action and there may be differential
interaction at the same molecular target between agents.
This and frequent association between neurological and
psychiatric disorders sustain an urge of psychiatric
research involving antiepileptic drugs.
Keywords: anticonvulsants, glutamate, GABA, Na, Ca
channels.
THERAPEUTICAL ALTERNATIVES IN THE
S H O R T- T E R M N O N - O R G A N I C S L E E P
DISORDERS
Ion Coşciug, Victor Lacusta, Lilia Coșciug, Inga Deliv,
Irina Padure
State University of Medicine and Pharmacy “Nicolae
Testemitanu”, Chisinau, Republic of Moldova
Objectives: The aim of the investigation was to study the
efficiency of acupuncture in association with oxytocin in
the treatment of non-organic short-term sleep disorders.
Materials and methods: There were 54 patients with short-
term non-organic sleep disorders investigated clinically
(criteria ICD 10), clinico-psychologically (scales Ch.
Spielberger, Zung W., Wessmann A.E., Rickes D.F., Sleep
efficiency index) and instrumentally (CT, MRI, EEG, etc.
to exclude organic brain damage).
Results: Investigations showed that acupuncture in
association with hypophyseal neuropeptides (oxytocin)
has not only a hypnotic effect (the sleep efficiency index in
patients treating with acupuncture was 0,6; this index in
patients treating with acupuncture in combination with
oxytocin was 0,72; in terms of ideal sleep this index is
equal to 1.0), but also leads to a considerable reduction of
affective disorders (anxiety, depression, dysphoria),

which, in fact, constituted the main cause of dyssomnia;
there might be simultaneously noted a more rapid and
durable effect of this therapeutical method, as compared to
acupuncture not associated with oxytocin.
Conclusions: Acupuncture in combination with oxytocin
may be an alternative treatment method in short-term non-
organic sleep disorders.
Keywords: acupuncture, hypophyseal neuropeptides,
short-term non-organic sleep disorders.
EPIDEMIOLOGY OF COMPLETED SUICIDE IN
SIBIU COUNTY
Raul Talau
European Hospital Polisano Sibiu, Romania
Suicide rates in Romania are reported to be higher than EU
averages, making this a national matter, with only a few
Counties having a coherent undergoing Prevention Plan.
Between 2010-2015 Sibiu situated itself with 3-4% under
the national rates, 243 completed suicides being reported
in this period, meaning that 7 to 10 people in 100.000
committed suicide in a year, having a peak with 48 cases in
2011 and showing a gradual decrease to 32 in 2015. Men
are overwhelmingly preponderant with 83.54% overall,
rates remaining fairly constant thru the years, females
having 20-30 times more attempted suicides, concurrent
with general findings. The elective method used to
complete suicide was hanging, due to the prevalence of
more violent attempts in men.
Age groups of 36-50 and 51-64 have the most completed
suicides, with 64 suicides (36.74%), respectively 54
suicides (24.23%). However, the elderly (group >65)
remain constant between 2010-2013 at 16.70-18.75%,
showing a gradual increase to 21.88% in 2015. This
alarming rise in this age group suggests that more efficient
prevention and social protection plans are needed for the
elderly, including an increase of Residential Homes.
Keywords: suicide, elderly, suicide prevention.
P S Y C H O T H E R A P Y V E R S U S
ANTIDEPRESSANTS IN DEPRESSION IN
BREAST CANCER
Ramona Adriana Schenker1, Puiu Olivian Stovicek2,
Michael Schenker3
1
University of Medicine and Pharmacy of Craiova,
Doctoral School, Craiova, Romania
2
Ti t u M a i o r e s c u U n i v e r s i t y, D e p a r t m e n t o f
Pharmacology, Bucharest, Romania
3
University of Medicine and Pharmacy of Craiova,
Department of Oncology, Craiova, Romania
The increased incidence of depression in breast cancer
patients is correlated with low compliance with specific
oncologic treatment with an unfavorable prognosis and
low quality of life. The pharmacological management of
depression is difficult to achieve due to the mechanisms of
action, relative effectiveness and multiple adverse effects
of antidepressants.
Some antidepressants may increase angiogenesis and
SSRIs treatment induces prolactinemia and decreased
sexual desire. Drug interactions between antidepressants
and antineoplastic pharmacological medication should
also be taken into account. Psychoncology can support a
differentiated therapeutic approach, depending on the
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
degree of depression, the particular psychological profile
of each patient. In breast cancer, younger premenopausal
women have an increased risk of psychological
impairment after cancer diagnosis and specific
oncological treatment may have more severe effects:
surgical treatment is mutilating, radiation therapy leads to
hair loss, chemotherapy can cause sudden menopause.
Psychotherapy can be more easily adapted to the
psychological needs of patients at any stage of diagnosis
and oncology treatment does not have side effects. The
psychologist can respond to the challenges of changing
daily activities and plans for the future, both for patients
and for the family. Psychological counseling can help
patients make decisions by improving their compliance
with treatment and stress management for better quality of
life and better prognosis.
However, there are situations where psychotherapy
associated with antidepressants is recommended,
depending on the degree of depression, the psychiatric
history, the age of the patients, the duration and the
compliance with the treatment.
Keywords: antidepressants, psychotherapy, breast cancer.
CARDIOVASCULAR COMORBIDITIES IN
UNIPOLAR DEPRESSION
Daniela Glavan1, Stefan Badescu2, Traian Barbu3
1
University of Medicine and Pharmacy of Craiova,
Romania
2
Doctoral School, University of Medicine and Pharmacy
of Craiova, Romania
3
Neuropsychiatry Clinic Hospital, Craiova, Romania
Depressive disorders play an important role in
cardiovascular pathology as a risk factor and as an
unfavorable prognosis to this pathology. On the other
hand, this type of comorbidity causes psychopathological
disorders, both anxious-behavioral and cognitive-type, in
the case of cerebrovascular damage.
The main cardiovascular comorbidities of depression are:
hypertension, myocardial infarction, coronary heart
disease, heart failure.
The retrospective clinical study was performed on a group
of 5054 patients admitted to the Neuropsychiatry Clinic
Hospital in Craiova with the diagnosis of unipolar
depressive disorder from January 1, 2008 to December 31,
2012, analyzing cardiovascular diseases as co-
morbidities.
Among the patients with psychiatric and somatic
diagnosis, the majority had only one co-morbidity, that of
a cardiovascular level. Cardiovascular comorbidities
(arterial hypertension, myocardial infarction, coronary
artery disease, heart failure) occurred in 1923 patients
from a total of 5054 patients studied.
The gender share of cardiovascular comorbidities in
unipolar depressive disorder is higher in women
(58.65%).
The association of cardiovascular comorbidity in a patient
with unipolar depressive disorder correlates with the
unfavorable evolution of the psychiatric disorder and the
amplification of the disabling effect
From a therapeutical point of view, tricyclic
antidepressants have important cardiac side effects:
proarrhythmic effects, prolonged QT interval, with the
risk of torsades de pointes; on the other hand, novel
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The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
antidepressants have cardiac protective effect, which
greatly improves therapeutic tolerance, while also
widening the range of therapeutic options for patients with
cardiovascular disease.
Keywords: depressive disorder, cardiovascular
comorbidities, risk factors.
AUGMENTING ANTIPSYCHOTIC TREATMENT
WITH PSYCHOTHERAPY FOR THE NEGATIVE
SYMPTOMS OF SCHIZOPHRENIA- A
NARRATIVE REVIEW
Octavian Vasiliu
Department of Psychiatry, University Emergency Central
Military Hospital ”Dr. Carol Davila” Bucharest, Romania
In patients diagnosed with schizophrenia, who receive
antipsychotic treatment but still present negative
symptoms, an augmenting strategy could be the addition
of a psychotherapy program. This indication is supported
by several guidelines, i.e. National Institute for Health and
Care Excellence (NICE) in the UK recommends arts
therapies (art therapy, music therapy, and body
psychotherapy) for schizophrenia with prominent
negative symptoms. Cognitive-behavioral skills training
in these patients may lead to improvements of the overall
clinical status and functioning, if it targets defeatist
performance attitudes and asocial beliefs. Cognitive
remediation was associated with significant
improvements of working memory, a component
suspected to feed the negative symptoms in
schizophrenia, and there are studies showing positive
results on behavioral negative symptoms.
In case of primary negative symptoms, CBT must focus on
behavioral activation and assertive techniques, which can
be rehearsed in individual therapy, but it's considered
useful to encourage the patients to participate in group
therapy sessions before they begin to apply new abilities
in real world. Another important aspect of CBT in these
patients is stimulation of recognition emotional
expression and achieving the ability to adequately
communicate with other people. Offering the possibility
to be involved in pleasurable and interesting activities as a
step to the construction of a daily schedule is very
important in fighting against affective flattening, apathy
and social withdrawal.
CBT could prove itself useful for patients with
schizophrenia and prominent negative symptoms, and it
involves techniques focused on both behavioral activation
and communicational abilities training.
Keywords: schizophrenia, antipsychotics,
psychotherapy, negative symptoms.
CYTOCHROMES – MEDICATIONS' TARGET
ENZYMES
Radu Gavril1, Raluca Frîncu2, Livia Lupșa1, Cristinel
Ștefănescu2
1
„Socola” Institute of Psychiatry Iași, Romania
2
Psychiatry Department, "Gr.T.Popa” University of
Medicine and Pharmacy Iași, Romania
In mental disorders, as much as in other diseases, there is a
large inter-individual variability in the drug response in
what concerns efficacy, tolerance and safety, all
10
determined by patient-related factors and the
environment, including drug associations, smoking, and
diet. This diversity of drug response is related to
absorption, distribution, metabolism and excretion, and
leads to a variation in the plasma concentration of the drug
but also in its interaction with the target, through enzymes,
receptors and carriers.
P450 2D6-cytochrome (CYP2D6), one of the most
important enzymes involved in drug metabolism, is
characterized by high variability in catalytic activity,
mainly caused by genetic polymorphism. More than 50
CYP enzymes have been identified in humans, but over
90% of all drugs are metabolized by just a few of them:
CYP1A2, CYP2B6, CYP2C8 / 9, CYP2C19, CYP2D6,
CYP2E1 and CYP3A4 / 5.
There are over 50 types of known CYP enzymes and
probably more are awaiting discovery and classification.
Not all individuals have the same CYP enzymes. 5-10% of
Caucasians have low CYP-2D6 enzyme activity, and
about 20% of Asians have low CYP-2C19 activity. Those
with reduced enzyme activity need to metabolize drugs on
alternative routes, which may not be as effective as
traditional pathways. These individuals need higher
plasma drug concentrations compared to people with
normal enzyme activity. Other individuals inherit high
enzyme activity and thus require lower plasma
concentrations compared to those with normal enzyme
activity. The genes for these CYP enzymes can now be
measured and can be used to predict which patients need
dose adjustment to obtain an optimal therapeutic
response.
Keywords: cytochrome P450, drug interactions, CYP
enzymes.
E VA L U AT I O N P R I N C I P L E S O F
PSYCHOPATHOLOGICAL DEFICIENCIES IN
THE NEURODEVELOPMENT OF CHILDREN
AND ADOLESCENTS
Victor Iovănel1, Simona Grujdin1, Nineta-Doinița
Magaon2
1
Individual Psychology Office, Craiova, Romania
2
„Charles Laugier” Highschool, Craiova, Romania
The evaluation of psychopathological deficiencies in
neurodevelopment is performed according to the
specificity of the disorder, the age and individual
peculiarities of the patient and the professional
methodological model of the evaluator. From this
perspective, knowing the clinical picture and the defining
conditions of the disorders is essential, thus the
presentation of the main nosographic markers (DSM-5 vs.
ICD-10).
Knowing the stages of development and the bio-psycho-
social characteristics of these stages is also crucial in
addressing the assessment and establishing the
psychodiagnosis, which is why the main theories of
human development are reviewed.
The psychological evaluation (standard or in-depth)
dynamic unfolds in successive stages (building the
assessor-client relationship, identifying the pain behavior,
specifying the level of the pain behavior in relation to the
chronological age, analyzing the origin of the pain
behavior, evaluating the role of the pain behavior in the

psychopathological organization and the interaction
system); it targets various levels (psychophysiological,
cognitive, affective, behavioral, interpersonal relationship
quality, defense mechanisms), and it requires the
observance of general principles and principles specific to
the methods of knowledge used by the clinical
psychologist ( clinical observation, clinical interview,
clinical consultation, standardized tests); the principles
are outlined in extenso in this presentation.
Keywords: cognition; psycho-neurodevelopenstages,
pain and behavior.
PREOPERATIVE DEPRESSION IN PATIENTS
WITH BREAST CANCER
Ramona Adriana Schenker1, Ileana Marinescu2, Michael
Schenker3
1
University of Medicine and Pharmacy of Craiova,
Doctoral School, Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Department of Psychiatry, Craiova, Romania
3
University of Medicine and Pharmacy of Craiova,
Department of Oncology, Craiova, Romania
Breast cancer is considered the most common form of
cancer, accounting for about 35% of all women diagnosed
with cancer. Oncological diagnosis has an impact on
psychological status with the appearance of depressive
symptomatology that can negatively influence the
evolution of cancer patients as well as their quality of life.
The factors correlated with the occurrence of breast cancer
depression are: menopause, hyperprolactinemia,
traumatic factors, personal or psychiatric antecedents, and
concomitant medication. Planning for mastectomy is
incriminated in the worsening of depressive
symptomatology, which correlates with an unfavorable
postoperative evolution. Depression can cause delay or
even refusal of surgery, mastectomy creates a
psychotrauma by loss of somatic identity, loss of
femininity and impairment of sexual life, while some
anesthetic drugs have depressive effect. Moderate or
severe depression is also associated with increased doses
of anesthetic drugs, and postoperatively with increased
levels of pain, severe insomnia, and sexual disturbances.
These mechanisms require a particular approach to
mastectomy. Psychotherapy has an important role in
screening depression in the preoperative stage, replacing
antidepressants and preparing patients for surgery.
Establishing the operator moment and adapting the
anesthetic treatment should be done in a multidisciplinary
team (psychologist, surgeon, oncologist, anesthetist).
The psychologist must follow the depressive
symptomatology both preoperatively and postoperatively,
the evaluation in dynamics and the immediate
psychological intervention can improve the oncological
evolution and quality of life of the patients.
Keywords: depression, mastectomy, psychotherapy.
LITHIUM AND ARIPIPRAZOLE TREATMENT IN
A CASE OF SCHIZOAFFECTIVE DISORDER
Margareta Cumpătă, Valentin Rădoi
Psychiatry Clinic Hospital „Prof. Dr. Al. Obregia”,
Bucharest, Romania
The potential for cognitive impairment may be important
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
in the course of schizophrenia, seeing as the patient's
treatment includes typical or atypical antipsychotics
which, primarily, block D2 receptors, and, as such,
increase the incidence of early and intense extrapyramidal
symptoms. Maintaining a functional equilibrium between
dopamine and serotonin becomes an important target in
psychopharmacology.
The 2nd generation antipsychotic aripiprazole is a partial
agonist at the D2 (KI=0.34nM) and 5-HT1A (KI=1.7nM)
receptors and an antagonist at the 5-HT2A receptor
(KI=3.4nM) while presenting high affinity for the D3
receptor and moderate affinity for the D4, 5-HT2C, 5-
HT7, α1 and H1 receptors.
Lithium's mechanism of action includes effects on all the
major neurotransmitter systems in the brain, increases in
GABA levels, neuroprotective effects which guard against
the excitatory toxicity determined by the low GABA
levels, and, following chronic administration, lithium
upregulates synaptosomal uptake of glutamate and, in
animal studies, it protects against glutamate-induced
excitotoxicity.
The authors present the positive effects of aripiprazole and
lithium treatment when schizophrenic symptoms are
associated with an affective disorder (expansive and/or
depressive) and medical imaging shows (probably
primary) hypofrontality and hypotemporality.
Keywords: aripiprazole, lithium, schizoaffective
disorder.
THERAPEUTIC STRATEGIES IN APPROACHING
BORDERLINE PERSONALITY DISORDER AND
HISTRIONIC PERSONALITY DISORDER
Aurel Nireștean, Monica Bilcă, Adina Maris, Emese
Lukacs
Psychiatry Clinic II, Târgu-Mureș, Romania
University of Medicine and Pharmacy Târgu-Mureș,
Romania
Borderline personality disorder and histrionic personality
disorder represent two well-defined and interfering
pathological entities. Thus, borderline features largely
integrate histrionic features, both of which having a
dominant genetic condition. Deficient self-esteem,
dependency, psycho-emotional instability, behavioral
hyperreactivity, and frequent association of depression
and suicide attempts have specific particularities of
borderline/histrionic personality disorder. This strongly
influences the quality of the relationship and the
therapeutic responsiveness.
Keywords: borderline personality disorders, histrionic
personality disorders, therapeutic responsiveness.
MANAGEMENT OF PSYCHIATRIC DISORDERS
ASSOCIATED TO MULTIPLE SCLEROSIS
Livia A Lupșa1, Raluca Frîncu1,2, Radu Gavril1, Cristinel
Ștefănescu1,2
1
“Socola” Psychiatry Institute of Iași, Romania
2
”Gr. T. Popa” University of Medicine and Pharmacy, Iași,
Romania
Up to 60% of patients diagnosed with multiple sclerosis
(MS) develop mental disorders, which are among the most
important factors associated with increased morbidity and
mortality in this neurological pathology.
11
The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
Although most of the psychiatric symptoms occur after
the establishment of a MS diagnosis, 2.3% of patients
show both neurological and psychiatric symptoms at the
onset, and between 0.2-2% of patients manifest only
psychiatric symptoms at first. Psychiatric comorbidities
may sometimes be difficult to diagnose, but are generally
responsive to treatment, which significantly improves the
patient's quality of life and therapy compliance.
According to the Medline, PsycInfo and Scopus
databases, the most common conditions associated with
MS are anxiety disorders, affective disorders - especially
depression, but also symptoms of mania, psychotic
disorders, pseudobulbar syndrome, psychoactive
substance abuse.
Treatment options vary according to each individual's
needs, the stage of the disease and the imaging findings,
and may include medication, psychotherapy, diet and
lifestyle changes.
Keywords: multiple sclerosis, psychiatric disorders,
psychiatric comorbidities in neurology.
NEW DIRECTIONS ON THE MANAGEMENT OF
VASCULAR AND ALZHEIMER DEMENTIA
Raluca Frîncu1,2, Livia Lupșa1, Radu Gavril1, Cristinel
Ștefănescu1,2
1
“Socola” Psychiatry Institute of Iași, Romania
2
”Gr. T. Popa” University of Medicine and Pharmacy, Iași,
Romania
Improving the quality of life of patients with dementia
does not require extra staff or very high incomes, but a
process of implementing several fundamental
management aspects (hospitalization, treatment,
occupational therapy options, a multidisciplinary team
involving a physician, a psychologist and an assistant).
Currently, the incidence of this disorder is about 5% at the
age of 65, reaching 30% over the age of 80. It is estimated
that there are 24.3 million people suffering from dementia,
with an annual diagnosis of 4.6 million new cases (one
case every 7 seconds).
Multi-commodity also affects the time of diagnosis, the
length of hospitalizations and costs as well. It is becoming
increasingly difficult in such cases to find an efficient
treatment which doesn't interfere with the patients' age nor
interact with their coexistent medication. The palliative
care sector is a relatively new branch in the medical field
of Romania. If 10 years ago only terminal oncological
patients would benefit from it, nowadays the service is
available for patients caught in the earliest stages of
chronic progressive diseases, in order to ensure a better
quality of life till the end of it.
Keywords: quality of life, palliative care, chronic
diseases.
BIPOLAR DISORDER ASSOCIATION WITH
C A R D I O VA S C U L A R A N D M E TA B O L I C
COMORBIDITIES
Daniela Glăvan1,2, Mădălina Aldea3, Dora-Izabela Stănia2,
Ion Udristoiu1,2
1
University of Medicine and Pharmacy of Craiova,
Romania
2
Clinical Hospital of Neuropsychiatry, Craiova,
Romania
12
3
Dăbuleni Hospital, Dăbuleni, Dolj, Romania
0.8% of the adult population is affected by type I bipolar
disorder, equally distributed in both sexes, while type II
bipolar disorder affects 0.5% population, being more
frequent in women.
There is a complex etiopathogenic relation between
bipolar disorder, cardiovascular disease and diabetes
mellitus.
In our study we evaluated the presence of cardiovascular
diseases and diabetes mellitus, socio-demographic
characteristics and the correlation between them and the
evolution of bipolar disorder for the admitted patients
during 1.01.2008- 31.12.2012 in the Clinical
Neuropsychiatry Hospital from Craiova, Dolj. The group
study included 270 patients, most of them being women
(57.41%).
Most of the admitted patients were aged between 49-64
years old (59.63%), followed by those aged between 25-
44 years old (32.96%). Only 2.59% of the bipolar patients
were over 65 years old, while the percentage of men
(2.96%) under 25 years old was more than the percentage
of women (1.85%). Most of the patients diagnosed with
bipolar disorder lived in the urban area (61.85%). Most of
the patients were active in the labor market (58.17%),
followed by the patients retired because of the disability
caused by the psychiatric disease (17.78%). High
statistical differences are observed between men and
women regarding their professional status, most of the
men being retired because of the disease, while women
continued to work. Cardiovascular disease was associated
with psychiatric disease in 14.26% of the patients, most of
them men, followed by diabetes mellitus (7.24%), more
frequent in women.
The study confirmed the correlation between the
evolution of bipolar disease and the presence of
cardiovascular disease or diabetes mellitus, highlighted
by the high number of hospital admissions, suggesting a
multidisciplinary approach in treating these patients.
Keywords: bipolar disorder, diabetes mellitus,
cardiovascular disease.
OBSESSIVE-COMPULSIVE PERSONALITY
D I S O R D E R – PA R T I C U L A R I T I E S O F
PSYCHOPHARMACOLOGICAL THERAPY
Aurel Nireștean, Emese Lukacs
Psychiatry Clinic II, Târgu-Mureș, Romania
University of Medicine and Pharmacy Târgu-Mureș,
Romania
The obsessive-compulsive personality disorder (OCPD)
and/or its maladaptive traits are often developed as
comorbid conditions in a variety of episodes and mental
diseases. The most common they are associated with
depressive and obsessive-compulsive clinical features.
Most of the clinical trials related to these comorbidities
confirm the role of serotonin metabolism dysfunction in
OCPD and the possibility of a positive response to SSRI
medication. The presence of obsessive-compulsive
features can be considered a predictor of the utility of
SSRIs when associated with depressive disorders without
this being confirmed in association with obsessive-
compulsive disorder.
Keywords: obsessive-compulsive personality disorder,

SSRIs, depression.
EVALUATION THROUGH PSYCHODIAGNOSIS
OF THE DISABILITY POTENTIAL IN
SCHIZOPHRENIA
Cerasela Sirbu1, Ileana Marinescu2, Dragos Marinescu2,
Stefan Badescu1
1
Doctoral School, University of Medicine and Pharmacy
of Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Romania
Schizophrenia is a potential cause of disability, the
defective assessment is clinically difficult, as a result,
psychodiagnosis methods and psychological tests can be a
real contribution
A numerical lot of 309 schizophrenic patients was
evaluated at Psychiatry Clinic II Craiova during the period
2016-2017. Clinic parameters such as: clinical type of the
disease, age, sex, educational level, number of relapses
were analyzed.
The assessment of the disabling potential was done by
using GAFS tests, MMSE, Karl Koch Tree Test. The
information obtained revealed important data in regard to
personality through the projective method, with a high
percentage of psychological vulnerability and
psychotrauma (death, couple separation, failure).
The correlation of the clinical and psychological
evaluation revealed the positive contribution of the
antipsychotic therapy.
Keywords: schizophrenia, GAFS, MMSE, Koch,
psychodiagnosis.
A LINK BETWEEN THE MICROBIOTA AND
EATING DISORDERS?
Ioana Pacearcă1, Floris Iliuță1, Mihnea Manea1,2, Gabriela
Puiu1,2, Bogdan Patrichi1,2, Mirela Manea1,2
1
„Carol Davila” University of Medicine and Pharmacy,
Bucharest, Romania
2
„Prof. Dr. Al. Obregia” Clinical Hospital of Psychiatry,
Bucharest, Romania
The gut microbiota is a community of microorganisms
that could reach a number as high as 400 trillion. It is
thought that the communication pathway between the gut
and the brain is bidirectional, involving the vagus nerve,
endocrine and immune pathways, the enteric and central
nervous systems.
Dysbiosis, the alteration in the microbial composition or
activity, influences the health of the individual. Also, it has
a role in some diseases as irritable bowel disease,
colorectal cancer and diabetes. Clinical studies have
shown that there is a link between the microbiota and
anxiety, depression, schizophrenia and recent research
indicate that gut microbiota could influence some neural
pathways involved in eating disorders.
It was found that patients with anorexia nervosa have
diminished microbial diversity which can be correlated
with modified eating behaviors. Recent studies suggest
that craving for the ingestion of some specific foods and
the appetite may be influenced by the gut microbiome, by
short-term and local effects and by long term changes.
Some researches have linked bulimia nervosa and binge-
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
eating disorder to antimicrobial medication use before the
therapy of the eating disorders. Modified appetite control
and perception of satiety may be the result of distorted
communication between the gut and the brain.
Recent studies and the scientific information about the
relation between microbiota and the eating disorders are
still limited, but it may lay the stepping stone for a therapy
based on microbiota modification for the eating disorders.
Keywords: microbiota, gut, eating disorders, dysbiosis.
CLINICAL AND THERAPEUTIC GUIDELINES IN
ALCOHOLISM
Stefan Badescu 1 , Ileana Marinescu 2 , Andreea
Dumitrascu3, George Badescu3
1
Doctoral School, University of Medicine and Pharmacy
of Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Romania
3
Clinic Neuropsychiatry Hospital Craiova, Romania
Alcoholism is currently the most widespread drug
addiction, with major medical and socio-economic
implications: globally, 16.6 million adults had AUD in
2013, inadequate alcohol consumption being the 5th risk
factor for premature death and disability; in 2006,
inadequate alcohol consumption had led to costs of $
223.5 billion in USA;
This paper aims at detecting alcohol-related clinical-
epidemiological elements during the period 2014-2015,
using a database of the Psychiatric Clinic II Craiova on the
N = 415 patients group
A growth trend of the number of patients with alcohol-
related psychiatric disorders was observed, in line with
global statistics, taking into account the development of
medical services with the increase of addressability to the
doctor.
The predominance of men was obvious with 83.7% in
urgent cases of alcoholism, the explanation being given by
the dynamics of the socio-economic and cultural activities
of the individuals.
Patients came mostly from rural areas, but with a small
lead over urban environment. The mentality in the rural
area and the fact that the main agricultural activity in the
southern area of Romania is viticulture explains this
difference.
The predominance of young and medium ages (35-64) is
noticeable, in line with specialized literature.
84.1% of the cases studied were associated with
personality disorders, the reason for hospitalization being
acute or subacute withdrawal. Approximately ¼ of these
patients had complications such as alcohol psychosis,
amnestic syndrome or toxic dementia syndrome.
Keywords: alcoholism, organic personality disorder,
withdrawal.
IMPACT OF COPING STYLE ON DIABETES
MANAGEMENT
Ștefan-Marian Ciocănaru1, Ancuța-Ioana Bumb1, Deiana
Roman2, Alin Albai2, Bogdan Timar3, Ion Papavă4
1
Student, “Victor Babes” University of Medicine and
Pharmacy Timisoara
2
Second Department of Internal Medicine, “Victor Babes”
University of Medicine and Pharmacy, Timisoara
3
Department of Functional Sciences, “Victor Babes”
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The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
University of Medicine and Pharmacy, Timisoara
4
Department of Neurosciences, “Victor Babes” University
of Medicine and Pharmacy, Timisoara
Diabetes is a chronic disease. The way the patient
manages to adhere to the activities recommended by the
doctor is very important. The present study analyzed how
the dominant style of coping of one person influences self-
care of type II diabetes (DZII). For this purpose, 126
patients with type II DZ were enrolled, whose dominated
coping style was evaluated with the COPE questionnaire
(problem-, emotion-, social- support-, or avoidance-
focused), and the adherence to self-care was assessed
using the SDSCA (Summary of Diabetes-Related Self
Care Activities) questionnaire.
A higher score on SDSCA was associated with improved
adherence. Patients with dominant emotion-focused
coping (29.4%) had the highest level (p=0.02) of DRSCA,
followed by patients with dominant social support-
focused coping (25.4%) and dominant problem-focused
coping (35.7%). The lowest SDSCA total score was in
patients with predominant avoidance-focused coping
(9.5%). The type of dominant coping style has a
significant impact on self-care activity adherence.
Keywords: diabetes, coping style, self-care activity
adherence.
D I F F I C U LT Y I N N O S O L O G I C A L
C L A S S I F I C AT I O N , R E S P E C T I V E LY
TREATMENT IN A PATIENT WITH FRONTAL
ATROPHY
Teodora Irina Drăghici
Psychiatry Hospital Voila, Romania
Introduction: The frontal lobe is involved in perform
complex psychic processes appreciating that it can be
considered as a model of cause-effect relationship
analysis. There is currently a known link between
prefrontal cortex atrophy and negative forms of
schizophrenia, but at the same time there may be
development of attention and memory disorders, followed
by temporospatial orientation disorder, instinctual
behavior that can affect the manifestation with moriatic
syndrome, pseudoexpansive, pseudodepressive, and
sometimes of the pseudodementia type.
Material and method: In the present case study, a patient
with a psychiatric history of at least 20 years old will be
present, the diagnosis of which he has retired was that of
paranoid schizophrenia. Later on, he develops a
predominantly affective symptomatology that puts the
clinician in difficulty in differentiation, mainly negative
symptoms of depressive symptoms, but also at the other
pole of expansive symptoms, confusion and intense
psychomotor agitation and behavioral misconceptions.
Results: Clinical picture analysis and paraclinical
investigations (especially cerebral imaging) as well as
psychological interventions lead us to see the
development of a severe depression syndrome, over an old
schizophrenia with quite prominent negative symptoms in
patients' clinical "stabilization" states.
Conclusions: To answer the questions:" How do we fit a
patient with anatomopathological frontal lobe changes ?" ,
on the one hand ,we need to know that from the
14
neuropsychiatric point of view, we can find depression in
the cortico-subcortical lesions, but also anger in the
frontoorbital lesions, as well as the disinhibition and
apathy, in the case of the frontal injuries on the median
line, and on other part an old schizophrenics with negative
symptoms suggesting a frontal lobe syndrome.
Keywords: negative symptoms, depression, diagnosis,
treatment.
EVALUATION OF EPIDEMIOLOGICAL RISK
FA C T O R S F O R N E U R O D E V E L O P M E N T
PATHOGENESIS OF SCHIZOPHRENIA
Iulia Delia Patru1, Alin Gabriel Vîlcea2
1
University of Medicine and Pharmacy of Craiova,
Romania
2
Antistress Medical Center Ilmad Craiova, Romania
The etiopathogenicity of schizophrenia benefits from a
complex pattern, the main factors involved in the
pathogenic mechanisms of the disease are genetic factors,
biological factors but also psychosocial and
environmental factors. Anomalies of neurodevelopment
are a combination of genetic vulnerability and epigenetic
factors. Etiopathogenic mechanisms are related to
schizophrenia with neurodevelopment abnormalities such
as social psychosis and gestational depression, infectious
and parasitic (influenza, cytomegalovirus, herpes zoster,
toxoplasmosis) infection, autoimmune diseases, Rh
incompatibility, gestational diabetes, eclampsia.
Consequences of these factors are hypoxic
encephalopathy of the newborn (APGAR score <5),
severe acute disorder following an imbalance between the
dopamine and glutamate system with triggering apoptosis
and atrophy of the brain structures. Apoptotic mechanisms
are amplification in the conditions of prematurity or
association of congenital heart abnormalities.
Epidemiological studies highlight the following data:
§Epidemiological data for newborns: a. Premature birth -
9.5%; b. Sub-contracted - 7.8%; c. Asphyxia at birth with
APGAR score <5 - 9%; d. Congenital heart abnormalities
not able to indicate degree of severity -2.5 0/00;
§Epidemiological data correlated with gestational period:
a. Stress and gestational depression - 18%; b. Respiratory
viral infection - 4.6%; c. Rh incompatibility - 1.5%; d.
Gestational diabetes - 8% of which 2 cases required
insulin therapy.
The relatively high incidence of potential vulnerabilities
to the risk of schizophrenia we suggest the possibility of
implementing a primary prevention program for this
condition.
Keywords: pathogenesis of neurodevelopment,
prevention mechanisms, epidemiological data.
CLINICAL AND THERAPEUTICAL MATTERS IN
THE ALZHEIMER DISEASE
Stefan Badescu1, Ileana Marinescu2, Alexandra Hromei3
1
Doctoral School, University of Medicine and Pharmacy
of Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Romania
3
Clinic Neuropsychiatry Hospital Craiova, Romania
Alzheimer's disease is one of the major public health

problems at a global level: in 2015, 48.8 million people
were diagnosed with dementia, with doubling of this
number every 20 years, being a major cause of disability
and mortality - the 6th cause of death in the US. Estimated
global costs in 2017 were $ 1 trillion, and that sum is
predicted to double by 2030.
This paper aims to evaluate clinical-epidemiological
aspects characteristic of Alzheimer's dementia during the
period 2012-2016, using the database from CSM Craiova,
constituting lot N = 410.
The study shows that Alzheimer's disease is the major
pathology of cognitive impairment - over one third - in line
with global data.
Patients over the age of 60 appear to be the most affected
population. By age group, we notice that almost half of the
total number of patients is represented by the 70-79 age
range, with a clear predominance of female gender.
The structure of the group is predominantly represented
by patients from urban environment, which is explained
by educational shortcomings and mentalities specific to
the rural environment, decreasing the level of
addressability to the doctor.
Keywords: Alzheimer's dementia, cognitive impairment,
disability.
THE PSYCHIATRIC DISORDERS IN HIV
INFECTED PERSONS
Iuliana Mariana Țîru
Clinical Hospital of Neuropsychiatry, Craiova, Romania
Introduction: The human immunodeficiency virus
infection remains one of the current medical problems that
draws to itself a constellation of disabling conditions.
These include psychiatric disorders that may have a fatal
outcome in the absence of adequate interdisciplinary
therapy. The most common disorders are caused by both
HIV-mediated primary affection in the nervous system, as
well as the overlapping of the associated multiple
pathology and the side effects of the medication.
Objectives: The study aims to analyze the epidemiological
data of patients diagnosed with HIV as well as the clinical
and evolutionary aspects of psychiatric disorders
developed by them.
Methods: The study group included 50 newly diagnosed
HIV patients registered in the Regional Monitoring Center
for HIV / AIDS during the period 01.01.2015-27.07.2017.
Patients were evaluated neuropsychiatric by using the
following: Global Functional Scale (GAF), Beck
Depression Scale, Hamilton Anxiety Scale, SADS
Affective Disorder and Schizophrenia and the Mini
Mental Scale Evaluation (MMSE).
Results: It was highlighted the development of 3 main
syndromes: affective, deterioration-dementia and
psychotic. The major recurrent depressive disorder was
the most common amongst study group`s patients with a
43% incidence. Out of these, 28% had autolytic ideas.
16% of subjects in the study group developed AIDS-
related dementia and 75% of them cognitive impairment.
Psychotic episodes have been rarely found (5%), having
occurred in the advanced stages of the disease.
Conclusions: The emergence of psychiatric disorders
during the course of HIV infection is a negative prognostic
factor that may lead to complications and impairment in
the quality of life. An efficient multidisciplinary
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
collaboration is recommended for the adequate
management of comorbid psychiatric disorders, taking
into account the medical status of the HIV-positive patient.
Keywords: HIV, depression, comorbidity.
ANALYSIS OF ORGANIC AND PSYCHIATRIC
C O M O R B I D I T I E S I N PAT I E N T S W I T H
SCHIZOPHRENIA DURING ANTIPSYCHOTIC
TREATMENT
Octavian Vasiliu, Daniel Vasile, Andrei G. Mangalagiu,
Bogdan M. Petrescu, Cristian A. Candea, Corina Tudor,
Daniela Ungureanu
Department of Psychiatry, University Emergency Central
Military Hospital ”Dr. Carol Davila” Bucharest, Romania
Background: Schizophrenia is associated with reduced
life expectancy and impaired quality of life, and one of the
main reasons for these findings is the high rate of organic
(i.e. metabolic syndrome, diabetes mellitus) and
psychiatric (i.e. alcohol dependence, personality
disorders) co-morbidities.
Methods: We analyzed all medical charts of patients
diagnosed with schizophrenia according to the DSM 5
criteria evaluated in our department during the last 2 years.
The objectives of this analysis were (1) to find the most
frequent co-morbidities, (2) to determine the incidence of
cases with at least one co-morbid condition, and (3) to
verify if there is a correlation between age, gender, and
number of somatic and psychiatric disorders detected.
Results: A total number of 87 patients, mean age 48.3
(range 18-73), 48 women and 39 males, mean duration of
illness 14.1 years, were included in the analysis. Mean
number of comorbid diagnoses was 3, and the most
frequently identified pathologies were obesity, arterial
hypertension, chronic hepatitis (viral and/or nutritional),
nicotine dependence, alcohol dependence, with calculated
incidence of 51.7%, 27.5%, 25.2%, 79.3%, 37.9%. At
least one comorbid condition was detected in 86.2% of all
patients with schizophrenia. No significant correlations
between age and somatic (p=0.188) or psychiatric
disorders (p=0.261) were found. No significant
differences between male and female were detected.
Discussion: Patients diagnosed with schizophrenia need to
be thoroughly examined by an interdisciplinary team,
because of the high risk of undetected or therapeutically
neglected comorbidities, which can further decrease their
life expectancy and quality of life.
Keywords: schizophrenia, comorbidities, quality of life.
THE BURNOUT SYNDROME AND THE
P E R C E P T I O N O N M E N T A L H E A LT H
DISORDERS AMONG MEDICAL STUDENTS AND
YOUNG DOCTORS
Elena-Nicoleta Bordea, Liana Kobylinska, Angelo
Pellegrini
Psychiatry Hospital Titan ”Dr. C. Gorgos” Bucharest,
Romania
University of Medicine and Pharmacy ”Carol Davila”
Bucharest, Romania
Except the somatic consequences upon the individual,
health professionals suffering from burnout symptoms
might also affect their attitude towards patients.
The aim of the present study was to investigate the burnout
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The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
symptoms of medical students and young doctors and to
see whether there is a correlation between these symptoms
and the attitude towards patients diagnosed with various
mental health disorders
Materials and methods: An on-line burnout questionnaire
was completed by 32 resident doctors, 66 medical
students and 21 specialist doctors, aged 18 to 40 years,
over a period of four days, during Brain Awareness Week,
2018. They were also asked to score a series of symptoms
representative for various mental health disorders. The
data were analyzed using SPSS 22.0 and Excel. Chi-
square, Kruskall-Wallis and Binomial testing were
employed.
Results: 19 to 26% of the responders in each group met the
cutline for the diagnosis for burnout, whereas between 10
and 32 % of the responders in each group were at risk of
developing burnout, without meeting the cutline for the
diagnosis yet. There were significantly less health
professionals with a risk of burnout among the specialist
doctors (p=0.002, both in comparison to the students, as
well as with the resident doctors). Also in the group of
specialist doctors, burnout was much more frequent in
males than in females (p=0.008, χ2(21,2)=7.07). There
were no differences in the perception of the patients with
mental health problems according to the burnout score,
neither were there differences between the 3 groups. Most
of the professionals attributed maximum severity scores in
all disorders.
Conclusions: Even if the burnout rates and the risk of
burnout are high in medical students and young doctors,
there doesn't seem to be a connection between the degree
of burnout and the perception on the symptoms of patients
with mental health problems.
Keywords: burnout syndrome, medical students, resident
doctors, specialist doctors, attitude towards patients with
mental health disorders.
NEUROIMAGING PRINCIPLES IN
ALZHEIMER'S DISEASE
Roxana Mihaela Folcuți1, Dan Gheorghe Mălăescu2,
Ileana Marinescu3
1
Titu Maiorescu University, Department of Radiology,
Bucharest, Romania
2
Titu Maiorescu” University, Department of
Morphopathology, Bucharest, Romania.
3
University of Medicine and Pharmacy of Craiova,
Department of Psychiatry, Craiova, Romania.
Alzheimer's disease is a progressive neurodegenerative
disease that has become one of the most common diseases
in the aging population, being the primary cause of
cerebral atrophy. Therefore, it is crucially to develop new
approaches for early and accurate recognition of
Alzheimer's disease.
Current diagnosis is based on clinical and neuroimaging
assessments. Computed Tomography and Magnetic
Resonance Imaging are the most common neuroimaging
methods used in the present days and are mainly based on
nonspecific features as atrophy, which is a late stage in the
progression of the disease. Nevertheless, CT scan and
MRI are considered to be the appropriate imaging
methods in Alzheimer's disease imaging diagnosis. The
main criteria for CT scan diagnosis includes medial
16
temporal lobe atrophy with widened sulci,
disproportionate atrophy of the hippocampal formations,
enlargement of the temporal horns of the lateral ventricles
and of the sylvian fissure. The most important feature in
the early diagnosis, with a predictive accuracy of 91% is
represented by dilatation of the perihippocampal fissure.
The main MRI findings associated with Alzheimer's
disease are the atrophy of the entorhinal cortex and of the
hippocampus, along with diffuse cerebral atrophy. The
accurate measurements of the temporal horn, lateral
ventricles, third ventricle, hippocampus, amygdala,
cingulate gyrus and head of the caudate nucleus are also
important criteria in MRI diagnosis.
MRI is considered to be the preferred routine
neuroimaging examination in Alzheimer's disease,
although there are a few other neuroimaging techniques
like PET-CT, SPECT-CT, functional or volume MRI that
hold promise and may yield along with CT and MRI
acceptable neuroimaging markers in initial Alzheimer's
disease diagnosis.
Keywords: Alzheimer's disease, atrophy, neuroimaging.
STUDY ABOUT DEPRESSIVE DISORDERS
AFTER ISCHEMIC STROKE
Denisa Floriana Vasilica Pîrşcoveanu1, Valerica Tudorică1,
Dragoș Marinescu2, Ramona Adriana Schenker3
1
University of Medicine and Pharmacy of Craiova,
Department of Neurology, Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Department of Psychiatry, Craiova, Romania
3
University of Medicine and Pharmacy of Craiova,
Doctoral School, Craiova, Romania
Objective: The aim of study was to evaluate the depressive
disorders in patients with ischemic stroke. We studied
depressive disorders after ischemic stroke in left carotid
territory in comparison with right carotid territory.
Material and method: We studied 135 patients (75 men
and 60 women, age between 62 and 82 years, with mean
level of educational of 9.5 years). The study proceeded for
one year. We performed to all patients a CT scan
examination. The depressive mood was evaluated by
Hamilton Depression Rating Scale and by Beck
Questionnaire. We estimated the motor performances
using Rankin Scale. The patients were divided in 2 groups:
group I consisted in 70 patients with ischemic stroke in left
carotid territory, with 1.60 points on Rankin scale and the
group II consisted in 65 patients with ischemic stroke in
right carotid territory, without aphasia, with 2.05 points on
Rankin Scale. Our evaluations were made at the baseline,
6 months later and after 1 year. The results were analyzed
by Student′s test (p ‹ 0.05 considerable statistical)
Results and conclusions: Depressive disorders were
observed in both groups, with no significant difference
according to the territory of ischemic stroke. The results
differed significantly only according with the severity of
motor deficits, but we cannot generalize this observation
because of the small number of patients.
Keywords: depressive disorders, ischemic stroke.
CORRELATIONS BETWEEN DEPRESSIVE
PATHOLOGY AND COGNITIVE DEFICIENCIES
Mihnea Costin Manea1, Maria Gabriela Puiu1,

Floris Petru Iliuță1, Anca Oana Dragomirescu1,
Ioana Anca Pacearcă1, Oana Manea2
1
“Carol Davila” University of Medicine and Pharmacy,
Bucharest, Romania
2
PhD student, C.F. 2 Hospital, Bucharest, Romania
Depression is one of the most common affective disorder,
ranked in 2004, according to the WHO, as the third cause
of global medical pathology, and is estimated to be the first
to place by 2030.
Cognitive deficits are part of the major diagnostic criteria
for major depressive disorder, according to DSM V.
Impairment of cognitive functions interferes with the
ability of depressed people to carry out daily activities,
which affects the personal, professional and macroscopic
lives of the world economic situation. Understanding
cognitive phenomena in depression and quantifying them
is a useful tool in clinical management of patients.
This paper aims to highlight the correlation between
cognitive deficits and depressive pathology. We used a
control batch composed of healthy subjects and a group of
patients diagnosed with depressive pathology. Each batch
was represented by 23 subjects. The paper starts from the
hypothesis that there is a direct correlation between the
intensity of depression and the degree of cognitive
impairment. We followed the difference in the severity of
cognitive impairment in the control group subjects
compared to the depressed subjects, with the latter
increasing the intensity of cognitive impairment.
Parallel distribution of the results of the two types of
Connections tests, both in the control group and in the
group of patients with depression. As a method, we used
the Connections test in two variants to evaluate different
cognition functions: in the simplest version, the test is
designed to assess psychomotor speed, and in the complex
version, the executive function. The executive function
mainly refers to the ability to solve problems, so it has
implications in all aspects of life. Problem solving
involves constructing a mental representation of the
problem, finding appropriate solutions to change the
situation and acting in this regard.
According to the obtained data, the subjects in the control
group had better outcomes than those in the group of
patients with depression, both in the simple variant of the
tests (15.41 versus 7.64) and in the case of the complex
variant (13.14 against 6.2). These results confirm the
hypothesis of altered cognitive functions (in this case
psychomotor speed and executive functioning) in patients
diagnosed with depression disorders versus those with no
psychiatric problems diagnosed.
Keywords: depression, cognitive disorder, problem
solving.
BIOLOGICAL AND PSYCHOLOGICAL
POSSIBLE MARKERS IN THE SUICIDAL
ATTEMPTS
Eduard-Nicușor Bondoc1, Ileana Marinescu2
1
University of Medicine and Pharmacy of Craiova,
Doctoral School, Romania
2
University of Medicine and Pharmacy of Craiova,
Romania
To properly assess the patient with suicidal risk, bear in
mind the context and polymorphic multifactorial etiology,
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
including bio-psycho-socio-cultural dimensions.
During a retrospective study we have analyzed 30 subjects
having subclinical depression in the past, involved in
psychotherapeutically process in the last 5 years, which
gradually returned with a post-partum depressive episode.
The subjects were between 20 and 38 years of age, without
psychotic disorders, selected by psychological criteria.
Results: In patients' psychopathological profile we found
depression, anxiety, affective instability of polymorph
aspect, depressive, anxious, interpretative tendencies.
These manifestations correlated significantly with
profiles obtained from the Beck and Hamilton scales,
often dominated by existential impasse with depressive
and anxious tendencies. Conclusions: We found many risk
factors associated with suicidal behavior in patients with
post-partum depressive disorder: age under 35, socio-
familial and precarious economic status, childhood abuse,
disharmonic family relationships, psychotrauma (abuse),
emotional instability, accentuated personality, subclinical
psychiatric suffering, a heredocollateral history of mental
illness, past history of suicide attempts, low cholesterol
levels.
Keywords: cholesterol, suicidal behavior, depression.
POLYMORPHISM OF DEBUT SYMPTOMS IN
DEMENTIA - CASE STUDY
Marina Buzut, Mihaela Cracan, Adina Cramă, Roxana
Chiriţa, Alexandra Boloş, Ilinca Untu
“Socola” Institute of Psychiatry, Iasi, Romania
Introduction: Middle age is the period between 45 and 65
years. Psychiatric disorders that occur now include both
the pathology of the adulthood and a pathology of its own,
due to aging. Framing psychotic phenomena, affective
symptoms, behavioral changes, as independent
nosological entities, as a manifestation of a physical
illness or as the onset of dementia is difficult at first. In this
case, a detailed physical and mental assessments
associated with brain imaging tests are required to
establish a correct diagnosis and to initiate specific
treatment.
Material and method: We present the case of a 62-year-old
patient with physical illnesses, at the first admission in a
psychiatric hospital for a sudden, polymorphic
s y m p t o m a t o l o g y, w i t h : d e c o n s t r u c t i o n ,
depersonalization, disinhibited behavior, auditory
hallucinations, perverted appetite, episodes of
psychomotor agitation, alternating with episodes of
apathy.
Results / Discussion: Ruling out a decompensation of a
physical illness or a metabolic imbalance directly
responsible for the patient's mental state, brain imaging
results, psychological tests, and patient monitoring over a
period of 3 months (as between first and second
hospitalization) support the diagnosis of dementia and a
antidemential treatment is initiated.
Conclusions: Psychiatric symptoms occurring in middle
age may represent the onset of a mental disorder, may be
the consequence of metabolic imbalances or physical
illness, or may constitute the onset of dementia. The
importance of proper framing is crucial, as a prompt
diagnosis allows early treatment.
Keywords: early dementia, prompt diagnosis,
dissociative elements, middle age.
17
The XIth National Conference of Biological Psychiatry and Psychopharmacology Craiova, April 18-21, 2018: Abstracts
COMMON NEURO-BIOLOGICAL LINK
BETWEEN THE EATING AND THE AFFECTIVE
DISORDERS
Traian Purnichi1, Ioana Pavel1, Diana Mihalcea1, Mihail
Pârlog2, Ileana Marinescu2
1
MD private practice, Craiova, Romania
2
University of Medicine and Pharmacy of Craiova,
Romania
Introduction: The environment, social settings, genetics
and personal interpretations of events, as well as the
capacity to cope with the elements that come together as
the person develops and interacts seem to play an
important role when confronted with an eating disorder
(ED). The main trait of this disorder can be found in the
psychosomatic medicine. The key aspect of all these
disorders is that they are enduring, relatively immutable
conditions that represent a baseline substrate of impaired
addictedness, of deficiencies, or distortions that limit the
capacity to adapt successfully to stress. That means that
the genetic factors in their relationship with the
environment can modulate the relationship between the
stress effects on the person's health. But genes do not code
a specific psychiatric disorder, nor any symptom, but they
do code for proteins and epigenetic regulators responsible
for this information processing in brain circuits.
Disscussions: Therefore, the neurotrophines are involved
in different mental problems (Ex: major depressive
episode). An association between MDE and
polymorphism of the brain derived neurotrophic factor
(BDNF) gene was reported. The family of neurotrophins
contains four proteins: nerve growth factor (NGFB),
brain-derived neurotrophic factor (BDNF) and
neurotrophins 3 and 4/5 (NTF3 and NTF4/5) and they play
important roles in proliferation, differentiation and
maintenance of neurons in the central and peripheral
nervous system. Neurotrophins have been shown to be
involved in different mental diseases like major
depression. An association between Eating Disorders(ED)
and polymorphism of the BDNF gene was reported. The
Val66Met polymorphism (rs6265) of the BDNF gene is
proved to be associated with anorexia.
18
Evidence show that the sympathetic nervous system, the
Hypothalamo-Pituitary-Adreno-medullary (HPA) axis
and the inflammatory response system form a major chain
reaction released by the immune complex. The interaction
established among these systems and the central
autonomic network which includes both prefrontal and
limbic cerebral structures form an internal regulation
system through which the brain controls visceromotor,
neuroendocrine, and behavioral responses that are critical
for adaptability and health, thus explaining the diversity of
psychosomatic symptoms starting with a slight nausea
sensation and ending with severe insomnia. The serotonin
transporter (5-HTT), encoded by the SLC6A4 gene, may
also have an important role in eating disorders. The
promoter region contains a functional insertion/deletion
polymorphism with two common alleles that have been
designated the short (*S) and long (*L) alleles. Meta-
analysis showed that the *S allele could represent a
moderate but significant risk factor that increases the
vulnerability for ED.
Because 5-HT is decreased just like in depression, ED are
treated using antidepressants, serotonin reuptake
inhibitors being the most frequently prescribed. High
doses of SSRIs are usually prescribed in eating disorders.
Information about genetic variations of cytochrome P450
could facilitate pharmacotherapy by preventing the
administration of high doses in poor metabolizers and
identify rapid metabolizes who may require higher doses
for efficacy.
Conclusions: There are several genes with an
essential role in the regulation of eating behavior and
could be involved in the etiology. ED can be treated using
antidepressants (SSRIs) considering genetic alterations in
the serotonin receptor. Taking the low levels of BDNF in
patients with ED and depression, using drugs that increase
the BDNF levels and/or BDNF gene therapy are possible
therapeutic approaches. When associated with
depression, ED symptoms are more severe.
Keywords: eating disorder, genes, antidepressants.
***
REVIEW ARTICLES

A REVIEW OF PERFORMANCE-BASED
EXECUTIVE FUNCTION TASKS IN ADULTS WITH
AUTISM AND NORMAL INTELLIGENCE
Ilinca Mihailescu1, Alina A. Frunză2, Emanuela L. Andrei3, Florina Rad4,
Iuliana Dobrescu5, Mirela Manea6

Abstract
Executive functions (EF) are a family of complex
cognitive processes which are necessary to guide our
thinking and behaviors towards certain goals. Research
into executive functions in Autism spectrum disorder
(ASD) has mainly been focusing on children and
adolescents, and less on adult populations. The purpose of
this article is to review the body of research that has
investigated the results obtained by adults with ASD and
normal levels of cognitive ability on performance-based
tasks of executive functions. To this aim, we synthesized
five executive functions: inhibition, cognitive flexibility,
planning, working memory and generativity and the
results of the studies included are presented in terms of the
specific tasks employed for each. The results of the 48
studies reviewed in this article are highly variable,
possibly due to the considerable differences in the methods
employed, but also perhaps through a phenotypical
heterogeneity of the patterns of executive functions in ASD.
Key words: autism, executive functions, adults
Rezumat
Funcțiile executive (EF) reprezintă o familie de
procese cognitive complexe, ce sunt necesare pentru a ne
orienta gândirea și comportmentele către anumite
obiective. Studiul funcțiilor executive în Tulburările de de
spectru autist (TSA) s-a concentrat în general pe populații
de copii și adolescenți, și mult mai puțin pe cele de adulți.
Scopul lucrării de față este acela de a trece în revistă
studiile care au investigat performanța subiecților adulți
cu TSA dar cu nivel normal de inteligență, la diferite
sarcini ce implică funcțiile executive. Astfel, sunt
sintetizate cinci funcții executive – inhibiția, flexbilitatea
cognitivă, planificarea, memoria de lucru și
generativitatea, iar în cadrul fiecăreia dintre acestea sunt
prezentate rezultatele studiilor în funcție de sarcinile
specifice utilizate. Cele 48 de studii incluse în analiză se
remarcă printr-o variabilitate foarte mare a rezultatelor
obținute, ce ar putea fi explicată prin diferențele
semnificative existente între metodologiile alese dar și
printr-o heterogenitate fenotipică a patternului funcțiilor
executive în TSA.
Cuvinte cheie: autism, funcții executive, adulți

Executive functions (EF) are a family of complex
cognitive processes, coordinated by the frontal lobes,
which are necessary to guide our thinking and behaviors
towards certain goals. Executive functions help the human
mind in making decisions, setting goals, organizing,
planning, focusing, learning, etc. Thus, executive control
is part of the adaptive mechanisms of the human mind,
which we need in all the activities of everyday life.
The history of the executive function concept is
closely related to the researchers' attempts to define the
functions of the frontal cortex, especially of the prefrontal
cortex, as decades ago, it was considered that the executive
functions are those functions that define the prefrontal
cortex activity. With the progress of neuroanatomy
research, the perfect equivalence between EF and PFC
functions has been left aside, as it has been shown that
through the many connections that the PFC establishes
with other cortical and subcortical regions, it is also
involved in other processes that go beyond the limits of
executive control. Moreover, the numerous structural and
functional neuroimaging studies conducted over the last
decades have shown that executive control involves a
number of other regions besides the PFC, which vary
depending on the executive function in question (1).
From the first mention of a possible deficit in
executive functions in autistic individuals, stated by
Damsio and Maurer in 1978, to date, countless studies on
populations of subjects with autism included various
types of assessments of executive functions. Most of these
studies focused on child and adolescent populations and
only in the last decade and a half have a significant
number of researches on adult populations emerged.
These studies are dominated by a very high variability of
the obtained results, with at least two contributing factors

1
Child and Adolescent Psychiatrist, MD, PhDc, Child and Adolescent Psychiatry Department, “Prof. Dr. Al. Obregia” Clinical Hospital of Psychiatry,
Bucharest, Romania
2
Psychiatry Specialist, MD, PhD, Neolife Medical Center, Bucharest, Romania
3
Child and Adolescent Psychiatry Resident, MD, Child and Adolescent Psychiatry Department, “Prof. Dr. Al. Obregia” Clinical Hospital of Psychiatry
4
Senior Child and Adolescent Psychiatrist, MD, PhD, Lecturer, Child and Adolescent Psychiatry Department, “Carol Davila” University of Medicine and
Pharmacy, Bucharest, Romania
5
Senior Child and Adolescent Psychiatrist, MD, PhD, Professor of Child and Adolescent Psychiatry, “Carol Davila” University of Medicine and
Pharmacy, Bucharest, Romania
6
Senior Psychiatrist, MD, PhD, Professor of Psychiatry, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
Corresponding author: Iinca Mihailescu - “Prof. Dr. Al. Obregia” Clinical Hospital of Psychiatry, Berceni Road, No. 4, Bucharest, Romania, e-mail:
ilinca_mihailescu@yahoo.com
Received February 26, 2016, Revised February 29, 2016, Accepted March 17, 2016
19
Ilinca Mihailescu, Alina A. Frunză, Emanuela L. Andrei, Florina Rad, Iuliana Dobrescu, Mirela Manea: A Review of
Performance-based Executive Function Tasks in Adults with Autism and Normal Intelligence

- the significantly different methods used (participants, subsequently be followed in the presentation of the results
executive functions analyzed and their tasks, objectives) of other executive functions.
but also a potential phenotypic heterogeneity of the
Executive Task/ Test
executive function pattern among people with autistic
function
spectrum disorders.
Inhibition -Go/NoGo Task;
This article is intended to be a review of the - Negative Priming
research that studied the issue of executive functions (EF) - Stop -Signal Task
in adults with autistic spectrum disorders (ASD). Thus, a - Stroop Task
search was conducted in a scientific database (Pubmed) - (Automated)Windows Task
using the following terms or their variations: "autism" or - Antisaccade Task
"Asperger" and "executive" and "adult". Out of the articles - The Hayling Sentence Completion Test
that resulted from the search we excluded those in which: - The Matching Familiar Figures Test
a) the minimum age of the subjects was less than 14 years - Flanker Test
and the mean age was less than 18 years; b) the subjects - AX-Continuous Performance Test (AY Condition)
included had the Full Scale IQ <70; c) the participants had - Virtual Classroom Bimodal Stroop (with or without
significant comorbidities such as genetic syndromes, distractors)
neurological disorders, significant somatic diseases - Automated Neuropsychological Assessment Metrics (ANAM)
(psychiatric comorbidities were not excluded); d) the Stroop Task
language of publication was one other than English; e) the Planning - Tower of London
articles were single case reports; f) the participants - Stockings of Cambridge *
- Tower of Hanoi
included had subclinical autistic features (“Broad Autism
- Zoo Map Test **
Phenotype”) or were represented by the parents or
- Key Search Test **
siblings of ASD patients; g) the theme presented was not
- Six Element Test **
relevant to this article. Thus, 71 original articles were - Tower of California ***
included, out of which 51 resulted from the actual search Mental - Wisconsin Card Sorting Test (WCST)
and 20 were identified in 6 review articles on this topic (2- Flexibility - Intra -dimensional/Extra -dimensional Shift Task (ID/ED) *

7). - Trail Making Test -B

The present article is part of a more extensive - Dimensional Change Card Sort Test
paper, structured into five areas of interest which also - Sternberg Response Bias Task
constitute the inclusion criteria for the studies in the main - Modified Card Sort ing Test
paper and each of these research papers addresses at least - Rule Shift Card Test
one of the following topics: 1) the performance in - SWITCH Task
executive function tasks (or the subjective evaluation) of - Proverbs ***
people with ASD compared to healthy subjects or other Generativity - Verbal Fluency Test (Category/ semantic Fluency, Letter/
clinical populations (i.e. schizophrenia, ADHD); 2) the Phonemic Fluency)
- Controlled Oral Word Association Test
relationship between EF and adult ASD symptoms or
- FAS Test
other clinical variables of interest (i.e. emotional
- Use of Common Objects
processing or recognition, mentalization, social cognition, - Design Fluency
etc.); 3) functional neuroimaging studies with EF tasks - Ambiguous Words Meaning Generation Test
among adult ASD patients; 4) the relationship between EF Working - Logical Memory I, II ****
in adult ASD patients and the functional outcome or Memory - Letter -Number Sequencing ****
quality of life parameters; 5) the influences that certain Verbal - Verbal Paired Associate Learning ****
types of pharmacological or psychotherapeutic treatments - Detroit Test of learning Aptitude: Oral directions, Word
have on EF in adult ASD patients. sequences
The current article focuses on the first of the - Verbal N -Back Tasks
above mentioned directions, namely on the performance - Non -Word Repetition Task
of adults with ASD with a normal intelligence quotient, - Digit -Span
compared to adults with no psychiatric pathology, during - AX-Continuous Performance Test (BX Condition)
specific tasks of executive functions (inhibition, cognitive - Oculomotor Delayed Response
flexibility, planning, working memory, generativity) (48 - N- Back Tasks
articles out of a total of 71). (Table 1). - Spatial - Span ****
INHIBITION Visual/ - Face Recognition ****
Spatial - Family Pictures ****
Inhibition, the executive function defined as the
- Digit -Symbol
ability to reject an automatic tendency in a specific
- Advanced Trail Making Test
situation, has been studied in relation to psychiatric
- Spatial -Span Task *
pathology, with most studies focusing on ADHD. In the - Spatial -Working Making Test
current review, a total of 19 studies was identified that
have reported the performance level of adults with ASD Table 1: Executive function tasks used in the studies of adults
compared to healthy subjects during tasks involving with ASD without Intelectual Disability
* Cambridge Neuropsychological Test Automated Battery
inhibitory control. Considering the high variability of the (CANTAB)
obtained results, which can be at least partially attributed ** Behavioural Assessment of the Dysexecutive Syndrome
to the variety of methods used in these studies (see Table (BADS)
1), we chose to review this research, depending on the type *** Delis-Kaplan Executive Function System (D-KEFS)
of task/ test that was used, a direction which will **** Wechsler Memory Scale- Revised (WMS-R)

20

Most studies using the Stroop test or its variants
for evaluating inhibitory control reported no significant
differences between adults with ASD and healthy
subjects. Thus, Ambery et al in 2006, comparing 27 adults
with Asperger's Syndrome with 20 healthy subjects, all
with a Verbal Intelligence Coefficient (VIQ) greater than
80, found no significant difference between groups on the
Stroop test interference score (8). Lopez et al., In 2005,
used a variant of the Stroop Test (The California Stoop
Test) without finding any differences between groups in
any of the test's parameters (Word-reading, Color-naming,
Interference, Switching) (9). Similar results for Stroop
type tasks were also obtained by Schmitz's 2006 research,
by Hill in 2006, and by Johnston in 2011, with no
significant differences between groups–(1012). Two other
studies have obtained mixed results, varying either
between the tasks used (13) or between the parameters
obtained in the same test (14). Thus, Sachse et al. showed
that adult subjects with high-functioning autism
performed Stroop test tasks in a significantly longer time
than healthy subjects, but the overall Interference Stroop
score did not vary significantly between groups (14).
Parsons et al. have evaluated the inhibitory response
through four Stroop-type tasks, namely a classic paper
version (from the D-KEFS battery), a computerised
variant (“Automated Neuropsychological Assessment
Metrics Stroop task”) and two Stroop tasks using virtual
reality techniques, with and without external distractors
("Virtual Classroom Bimodal Stroop with or without
distractors") (13). Thus, no significant differences were
obtained between ASD and healthy adults in the classical
Stroop test, the computerized or virtual reality without
external distractors test, but people with ASD had
significantly weaker results using virtual reality with
external, visual and hearing distractors (13).
Another type of tasks commonly used in studies
that looked at inhibitory control are the "Go / no-Go"
tasks, but the results, as with studies using Stroop tasks,
are varied, indicating both the existence of deficits among
adults with ASD – (1517) and the lack thereof
(10,16,18,19). Lai et al., in a comparative study on 64
adults with ASD (32 men and 32 women) and 64 healthy
adults (32 men and 32 women) found a significant effect
of the disorder on the results of a Go / no-Go task and the
lack of a relevant effect of the gender (15). In 2014 Wilson
used this task to compare the inhibitory response between
89 adults with ASD and 89 healthy adults, and, after
adjustments based on the Performance Intelligence
Quotient (PIQ), found significant differences between
groups with significantly more mistakes made by the ASD
group both at the Go (omissions) and the no-GO
(commissions) conditions, but with no differences in the
Beta coefficient (measure of response biases) (17). In an
attempt to determine a possible relationship between the
type of response to inhibitory tasks and the general arousal
state of adults with ASD, Raymakers et al. emphasize the
presence of a general state of overarousal in ASD
individuals. The authors of this study justify this
conclusion by describing an inhibition deficiency in a Go/
no-Go task with a fast presentation rate (1 second) and a
lack of deficit compared to healthy subjects when the
presentation of the stimuli takes place at 2 and 6 seconds
respectively (16). Two functional neuroimaging studies,
which included in the analysis the evaluation of emotional
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
stimuli (happy and sad faces) inhibition through Go/ no-
Go tasks, found no significant difference in performance
between the two groups groups (18,19). As the
aforementioned studies focused on functional
neuroimaging, the studied groups were very small
(approximately 15 participants per group) and thus,
although in Duerden's study the ASD subjects made a
noticeable number of errors, the difference was not
significant.
The "Hayling Sentence Completion Test" is an
instrument through which the initiation of the response
and the inhibitory control are measured. Thus, the first part
of the test involves the completion of certain sentences
(initiation of the response) by the subject being evaluated,
and the second part also involves the termination of
sentences, but with a word that is inappropriate to the
meaning of the sentence (inhibition of an appropriate
response). In 2011, Johnston, after using this test in a
comparative study on adult subjects with ASD, ADHD,
and healthy adults respectively, reported that adults with
ASD were significantly slower in inhibiting the prepotent
response and in completing section 1 of the test, related to
response initiation (12). Another study, conducted by Hill
and his collaborators in 2006 showed that although there
are significant differences between ASD adults and
healthy subjects concerning the time needed for the
completion of each of the two sections but also in terms of
the overall score, there is the possibility that these
differences are at least partially explained by the difficulty
of initiating a response, given that once the analysis is
adjusted according to the duration obtained for the first
part of the test, there was no longer a significant difference
in the latency of response during the second section of the
test (the task that involves inhibition) (11). Additionally, in
Hill's study, the total number of errors made in this test did
not differ significantly between the studied groups, whilst
another study using the Hayling test found that subjects
with ASD make significantly more errors than healthy
ones (11,20). No differences between groups on the
Hayling test were also reported by Baez in 2012 (21).
Another test that has shown the existence of
inhibitory function deficits in adults with ASD is the
"Antisaccade" task, in which the evaluated person,
looking at a static target, has to look at the opposite side of
the one in which a certain luminous stimulus appears
(22,23). Tasks related to inhibitory control that showed a
similar level of performance between adults with ASD and
healthy controls are the Flanker Test (21), the “Matching
Familiar Figures” test (12), and “AX-Continous
Performance Test” (24) - a two-condition test, one
investigating the inhibitory function and the second –
working memory.
MENTAL FLEXIBILITY
Mental (cognitive) flexibility defines an
individual's ability to continuously adapt their cognitive
strategies to deal with new environmental stimuli. This
cognitive function is often divided into two components -
a conscious, voluntary one used to shift from one task to
the other (“cognitive shifting”) and an involuntary,
unconscious component involved in fast adaptation to
new tasks/situations (“task switching”). The lack of
cognitive flexibility has often been incriminated as the
pathophysiological basis of certain symptoms specific to
the autistic spectrum, such as repetitive interests and
behaviours, adherence to routines, and so on.
21
Ilinca Mihailescu, Alina A. Frunză, Emanuela L. Andrei, Florina Rad, Iuliana Dobrescu, Mirela Manea: A Review of
Performance-based Executive Function Tasks in Adults with Autism and Normal Intelligence
Of the studies included in this review, 22
compared the performance of adult subjects with ASD
versus healthy subjects. Tasks that tested cognitive
flexibility varied (see Table 1), the most commonly used
being variants of the “Wisconsin Card Sorting Test” and
the “Trail Making Test”.
The “Wisconsin Card Sorting Test” (WCST) is
the most commonly used task in neuropsychology studies
for the evaluation of cognitive flexibility and from its
introduction in the mid-20th century until today, a number
of modified versions have emerged. In the classic version,
the test includes 4 key cards and 128 response cards, all
with geometric figures, cards varying in shape, colour or
number of geometric figures. The person being evaluated
must discover the rule by which the cards are sorted
(number, colour or shape) through successive attempts,
each followed by the evaluator's feedback. Once the rule is
discovered, the evaluated person must keep sorting the
cards, according to the discovered principle. After 10
consecutive correct answers, the rule changes without
notifying the evaluated person. The test's parameters, used
as dependent variables vary and among them there are: the
total number of errors, the number/ percentage of
perseverative errors (the Milner type – incorrect response
immediately after a completed category; the Nelson type –
incorrect response after another incorrect response in the
same category), the number/ percentage of non-
perseverative errors, the number of completed categories,
conceptual-level responses, etc. The variability of the
results reported by studies that investigated cognitive
flexibility in adult patients with ASD is quite large, but
equally unstable is the choice of test parameters
considered to be of interest in these studies. Keeping this
observation in mind, it is difficult to consider the results of
these research papers as significant or not in terms of
differences between adults with ASD and those included
in control groups.
Sumiyoshi et al, in 2011, after comparing 22
adults with ASD and 15 healthy adults, described the
presence of some cognitive flexibility deficits among
adults with ASD in solving the WCST test, as these
subjects made significantly more perseverative errors and
completed significantly fewer categories, but had a
similar reaction time (25). Significant differences were
also reported by Broden in 2017, Lopez in 2005, and
Rumsey et al. in their studies, the latter using a larger
number of test parameters (including non-perseverative
errors, conceptual-level responses) – (9,2629). On the
other hand, a number of studies could not identify
significant differences between ASD and healthy adults
(30), or the results were mixed –(8,3133). Thus, in 2014,
Yasuda, after comparing 33 adults with ASD with 33
healthy subjects matched by age, sex, education, and
intelligence quotient, showed that adults with ASD make a
significantly greater number of errors in the WCST test,
including Milner or Nelson type perseverative errors, but
the total number of completed categories did not differ
significantly (33). A study performed by Kiep in 2017 in an
attempt to compare cognitive flexibility performances
between genders, compared 99 men with ASD and 40
women with ASD, with 35 men and 25 women
respectively without a psychiatric disorder (32). The
results obtained in the WCST test showed that both male
and female adults with ASD made significantly more
22
perseverative errors, whereas the number of non-
perseverative errors and the number of completed
categories were significantly different only among male
participants (32).
"The Modified Card Sorting Test" is one of the
revised versions of WCST, that has common principles,
but with a few differences. Thus, there are fewer cards
(only 48 compared to 128), only 6 consecutive correct
responses are required to consider a category as complete,
and the changing of the sorting rule is announced by the
evaluator. The MCST test was also used in studies with
adult subjects with ASD, but all studies reported no
significant differences between ASD and healthy subjects
(11,34,35). The study done by Geurts et al. is one of the
few studies that have been based on older adult
populations, as the authors compared 23 subjects with
ASD with an equal number of healthy subjects, all aged
between 51 and 83, but there were no statistically
significant differences in the number of perseverative
errors made by them in the MCST test (34).
“The Trail Making Test” (TMT) is a tool that
measures processing speed together with cognitive
flexibility. Both activities included in the test involve
drawing lines, with the purpose of connecting 25 circles
randomly placed on an A4 page. In Part A of the test, which
measures the cognitive processing speed, the circles
contain numbers from 1 to 25, and in part B of the test, they
contain letters from A to L and numbers from 1 to 13 and
the person being evaluated must connect letters and
numbers alternately ("A-1-B-2-C [...]"). For both parts,
the time needed to complete the task is noted, and for the
cognitive flexibility evaluation, the most frequently used
measures are the TMT-B (execution time of part B) and the
'TMT B - TMT A' variable. Most studies using the TMT
test for assessing cognitive flexibility, comparing ASD
and healthy adults, did not find significant differences
between groups with respect to the TMT-B variable
(9,21,29,30,35,36), the TMT B - TMT A variable (34,35)
or the TMT-B with the time needed to perform the first part
as a covariate in the analysis (11). Two studies report
significant differences between ASD and healthy adults,
with a significantly longer time needed by the patients
with ASD to perform the B part (37,38), but none of these
studies tested the survival of a significant result after
taking into account the cognitive processing speed (TMT
A). Towgood et al., after finding no significant differences
between groups through simple comparison, have then
performed a multiple case series analysis (35). Thus, they
found that the performance of ASD subjects in a number of
tests, including TMT was heterogeneous, more variable
than the one of healthy subjects, participants showing
different weaknesses and strengths (35). In the case of the
TMT test, 19% of ASD subjects had TMT B and TMT B-
TMT A times above 2 standard deviations compared to the
mean of the control group and 28% of ASD subjects below
2 standard deviations (35).
The absence of deficits in the cognitive
flexibility of adults with ASD has also been reported in
other studies using less utilised tasks than the
aforementioned, such as the “Intradimensional/
extradimensional set shifting task” which is part of the
CANTAB tests battery (14), “SWITCH” (10), “The
Dimensional Change Card Sort” (21), “Rule Shift Card”
as part of the BADS tests battery (11) or “Proverbs”, as

part of the DKEFS tests battery (35). Two other studies
report significant differences among the ASD and control
groups, using less common tasks as well, such as a
computerised version of the Sternberg test (39), or even an
original set shifting task (40).
PLANNING
Planning is an executive function characterized
by formulating, analyzing and selecting ideas and actions
in order to achieve a particular goal. As it is the case with
other executive functions, planning is evaluated through a
multitude of tests (Table 1) with a wide range of variables
used. The most well-known tests are the “Tower of
London” and “Tower of Hanoi”, and these have numerous
adaptations.
All the “Tower of London” (ToL) tasks use the
same general principle, which involves the arranging of
three balls/ beads on three pegs, according to a pre-set
configuration shown by the evaluator. Variations of ToL
differ by the number of configurations that the person has
to perform (e.g. 10, 20, etc.), the difficulty of the task
quantified by the number of moves required to make the
configurations (there are tasks using configurations with
1-3 moves, with 3-6 moves, 4-7 moves, etc.), by the
presentation of the task (physical/ on-screen) and by the
parameters used as dependent variables. Of the studies
included in this review, three using ToL tasks have been
identified (34,41,42). Two of these studies include
groups of older adults with ASD (the mean age of adults
with ASD in the Davids et al. study is 58.6 and in Geurts's
study of 63.6), and all three studies fail to find significant
differences in performance between ASD and healthy
subjects in most comparisons of ToL variables (34,41,42).
The only mixed result was obtained by Davids et al. in
their study, reporting the lack of differences in the score
that quantifies the number of correctly solved
configurations and significant differences between groups
on the total planning and execution time (41). Another
study by Sachse et al. in 2013 used a ToL-derived
computerized task called “Stocking of Cambridge”, and
the results of the analysis also show the lack of significant
differences between groups (14).
The “Tower of Hanoi” (ToH) tasks, similar to
ToL, imply the existence of 3 bars as well, but in this case,
usually on the left bar, a number of disks (e.g. 3, 5, etc) are
placed by size, from the biggest disc at the bottom, to the
smallest at the top. The goal of the test is to move all of the
disks to get the same configuration on another bar, usually
the one on the right, taking into account a few rules. Two
studies used ToH tasks to compare the planning ability of
adults with ASD and of healthy individuals and the results
showed no differences between groups (32,36). In the
study of Kiep et al. from 2017 the differences were
analyzed considering gender, and the results were that
men and women with ASD had similar performances to
those of neurotypical adults (32). Lopez et al., in 2005,
used a modified version of ToH called "Tower of
California" and found that adults with ASD built fewer
towers than those in the control group (9).
In addition to these classical tasks that
investigate the cognitive planning ability, some
researchers have attempted to use tests that involve
solving tasks that are closer to those encountered in real
life. Tasks such as "Zoo Map" and "Key Search", both of
which are part of the “Behavioral Assessment of the
Dysexecutive Syndrome” (BADS) battery, evaluate
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
people's ability to plan a route on a map taking into
account certain rules and, respectively, to find a lost object
in a certain area drawn on paper.
The “Zoo Map” task is quite commonly used in
more recent studies and the search for routes on the map is
done in two separate sections. In the first section the route
must be planned by the evaluated individual, but in the
second more structured section, the participant only has to
follow certain predefined routes. For both parts, the
planning time, the actual execution time, the total time,
and an accuracy score in solving the problem are noted.
Variables most commonly used as indicators of planning
ability are those resulted from the first part of the test or
indicators resulting by subtracting the results of part 2 of
the test from part 1. Five studies used this task among adult
subjects with ASD, with no differences between them and
healthy subjects reported in three of those (20,35,41). Two
other studies, however, report a longer planning and
execution time for subjects with ASD (43), lower accuracy
(11), longer total time (43) and a lower total score (11) (all
parameters were reported for the first part of the test).
The “Key Search” task, which implies searching
for a lost object in a drawn area, requires, besides the
ability to plan, the ability to form strategy and to solve a
problem. In 2006 Hill used this task and, using a scoring
procedure that quantifies how efficiently the participant
covered the area investigated, did not find significant
differences the performance of adults with ASD compared
to a group of healthy subjects (11). Bramham in 2009,
using the same task, concluded that the 45 subjects with
ASD spent significantly more time in solving the task than
the 35 neurotypical subjects, but the accuracy in solving
the task did not differ between groups (43).
WORKING MEMORY
Working memory represents a complex
cognitive function involved in the temporary storage and
processing of information so that it can be manipulated
later on in different mental tasks or goal-oriented
behaviours. According to Baddeley's model, working
memory can be divided into three components - the
executive centre (which selects information, processes it
and directs it to one of the following components), the
phonological loop and the visuospatial sketchpad (44).
Thus, the tasks that test working memory, access one of
the two components of the working memory - the verbal
(phonological) or the visuospatial memory, by the nature
of the information needed to be manipulated.
The most common type of tasks in studies that
investigate working memory in general, but also in the
studies included in this review, are the “N-back” tasks.
Although there is a wide variation between the different
N-back tasks, the general principles remain the same.
Thus, the evaluated person has to correctly identify a
certain target (e.g. letter, drawing, human face, etc.),
according to the instructions received from the evaluator,
from a simple identification ("Press the button when the
letter F appears", O-back) to the identification of the target
when it appears twice in a row (1-back) and respectively
when the target is represented by a stimulus identical to the
one presented two positions behind (2-back). The most
commonly reported parameters in the studies are: the
reaction/ response time, the number of correct answers/
accuracy and the number of errors (by omitting the target
or by pressing false targets). Seven studies included in this
review used N-back tasks to compare working memory
23
Ilinca Mihailescu, Alina A. Frunză, Emanuela L. Andrei, Florina Rad, Iuliana Dobrescu, Mirela Manea: A Review of
Performance-based Executive Function Tasks in Adults with Autism and Normal Intelligence
between adult subjects with ASD and healthy controls. Of
these, five used tasks for the verbal working memory
(tasks with letters or numbers) –(21,26,4547) and two used
as tasks visual targets like simple drawings (48) or human
faces (49). All studies that analysed N-back tasks with
letters or numbers showed the lack of significant
differences between groups in terms of reaction/ response
times – (21,26,4547), of errors (46,47), or of correct
answers/ accuracy (21,26). Koshino et al in 2008, who
used a N-back task with human faces in their functional
neuroimaging study, found no significant differences
between the groups for the reaction time or the number of
errors made during a task (49). The study done by Lever et
al. in 2015, distinguished by the large number of subjects
(111 participants with ASD and 164 neurotypicals), used a
N-back task with black and white drawings of common
objects, thus accessing the visual component of the
working memory (48). The results of this study show the
presence of significant differences in terms of reaction
time between participants with ASD and healthy controls,
but with a similar number of correct answers (48).
In addition to N-back tasks, a large number of
other tests have been identified that evaluate the verbal (9
tasks) and visuospatial (8 tasks) working memory (Table
1). We will summarize, for each task, the number of
studies which reported significant differences between the
groups, the subjects with ASD being less well-performing
than the healthy ones ("diff sig."), the number of studies
without significant differences ("no diff.") and the number
of studies with mixed results ("mix"), when within the
same task there are significant differences between groups
in some test variables, but not in all of them.
Thus, the tasks used for the evaluation of the
verbal working memory were: “Logical Memory I” (diff.
sig.- 1 study (28) , no diff.- 2 studies (8,50)), “Verbal Paired
Associates Learning” (no diff.- 2 studies (8,50)), “Non-
word Repetition Task” (no diff.- 1 study (15)), “Span-
Counting Task” (no diff. - 1 study (21)), “AX Continous
Performance Test” BX Task (diff. sig. - 1 study (24)),
“Letter – Number Sequencing” (diff. sig. - 2 studies
(32,51), no diff.- 3 studies (9,45,50)), “Oral Direction” and
“Word Repetition” as part of the “Detroit Test of Learning
Aprtitude-2” battery of tests (diff. sig. - 1 study (52)).
The following results were reported after the
evaluation of the visuospatial component of the working
memory: “Spatial Span” (diff. sig.- 3 studies (34,45,50)),
“Oculomotor Delayed Response” (mix – 2 studies
(23,53)), “Spatial Working Memory” (no diff. - 1 study
(14), but with large effect size), “Face Recognition” (diff.
sig.– 1 study (50)), “Family pictures” (diff. sig.– 1 study
(50)), “Advanced Trail Making Test” (no diff.– 1 study
(54)), “Digit symbol” (diff. sig.– 1 study (54)), “Design
Memory I” (diff. sig.– 1 study (28)).
GENERATIVITY
Generativity represents the ability to
spontaneously generate new ideas and behaviors. A
deficient individual in this executive area lacks
spontaneity and initiative, may have poor speech and a
reduced capacity to engage in imagination games.
The studies included in this review used certain
phonemic and semantic verbal fluency tasks, but also
design (drawing) tasks to test generativity among adult
persons with various forms of autism. As with the other
executive functions studied and synthesized in this
24
analysis, the results reported in the 15 articles that used
either phonemic or phonemic and semantic combined
tasks for verbal fluency testing, are variable.
The most commonly used verbal fluency task is
the phonemic fluency task (with letters/ phonological) -
Controlled Oral Word Association Test (COWAT), which
requires a series of words to be generated, starting from a
certain letter, most often F, A or S, but also adaptations
done according to the native language of the participants,
within a fixed amount of time, usually one minute. The
number of correct words produced is recorded as a
parameter.
For the phonemic fluency tested by COWAT or
its variants, 6 studies (8,28,34,38,43,55) identified a
significant difference between the number of words
generated by the autism group and the control group with
fewer correct words produced by autistic participants,
while 8 studies (9,11,15,17,21,30,35,41) did not find a
significant difference between the number of words
generated by autistic subjects compared to the healthy
ones. One final article, which included 139 ASD
participants: 99 men and 40 women versus 60 healthy
subjects: 35 men and 25 women, reported mixed results
depending on the gender of the participants (32). Thus, in
the phonemic fluency test using the letters "K" and "M"
(adapted to the native Dutch language), significant
differences from the control groups were recorded only
for men with autism, not for women, and only for the letter
"K", not for the letter "M" (32).
In addition to phonemic fluency, within
generativity, the semantic (or category) fluency is tested as
well, for which the participant is asked to produce as many
words as possible from a certain category, most often
animals, but also others such as crafts, fruits and
vegetables, vehicles and others. The number of correct
words generated for a category in a certain time limit is
tested in this case as well.
Semantic fluency was tested in the same study by
Kiep in 2016 using two categories: animals and
professions, with mixed results depending on gender.
Significant differences were identified for men with
autism but not for women (32). Other 5 studies included
semantic fluency in the analysis, two of which identified a
significant difference between autistic and healthy
subjects (38,55), two did not report statistically significant
differences between groups (9,41), while Minshew et al. in
1992 obtained statistical significance only before
applying the Bonferroni correction (30).
Non-verbal or design fluency is another
parameter used to assess generativity, and a task
commonly used in its assessment involves three types of
drawing patterns, two simple designs and one involving
switching designs. Two studies that reported results on
this test have been identified, but the findings were
contradictory (9,21). Thus, Lopez in 2005 found
significant differences in the number of perseverations -
more in the group of autistic persons, for simple designs
(9), while Baez in 2012 reported significant differences
between groups only for the switching task (21).
CONCLUSIONS
This review of the studies, which compared the
results of adults with ASD and intact cognitive ability on
performance-based tasks of executive functions with the
performance of neurotypicals, brings forth a considerable

variability of the results together with a lack of consensus
regarding the patterns of deficits of executive functions in
this clinical population. Out of all the studies reviewed, we
found no executive function or even part of one to yield
conclusive results in either direction. Furthermore, some
studies draw attention to the heterogeneity of these
deficits even when considering relatively homogeneous
populations, with similar severity of the disorder and level
of intelligence, age and levels of education. This
considering, it is our opinion that in order to draw
pertinent conclusions regarding executive function
deficits in autism, it is imperative to employ the same
neurocognitive test battery in studies, replicated several
times, on large numbers of participants.
Moreover, there are other sources of uncertainty
besides differences in performance on executive function
tests, such as variability in the activation and connectivity
of different cerebral areas as found in neuroimaging
studies using EF tasks, or the relationship between EF
patterns and autistic core symptoms, other clinical traits or
even general level of functioning in daily life.
Finally, it is our belief that a more extensive
knowledge of the weak and strong points in executive
functioning of persons with ASD could provide valuable
information with regards to individualized therapeutic
interventions, tailored to each person's needs (e.g.
therapeutic measures to increase cognitive flexibility or
working memory, pharmacological interventions to lower
the overarousal for better inhibitory control, etc).
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ORIGINAL ARTICLES

ROMANIAN PSYCHIATRIC RESIDENTS' OPINION

ON FACTORS WHICH INFLUENCE THEIR
DECISION TO EMIGRATE AS CHALLENGE FOR
REFORMS IN EDUCATIONAL AND MEDICAL
SYSTEM IN PSYCHIATRY
Adriana Mihai1,2, Maria Silvia Trandafir3, Lavinia Duică4, Alex Mihai5,
Cosmin Lungu6, Anca Livia Chiriță7, Mihail Cristian Pîrlog7

Abstract: Our objectives were the prioritization exercises
of main factors related with psychiatric residents' decision
of emigrate could be a starting point of elaboration of a
strategy of reforms. The study is cross sectional evaluation
at national level, on a randomised selected sample of
Romanian psychiatric residents' opinion on factors which
influence decision of migration in EU countries. In results
we noticed that 75% of psychiatric residents intend to work
abroad (71.66% for a limited period of time and 28.33%
intend to emigrate) and 5% intend to leave the speciality.
“Better working conditions” for 37.31% residents and
“respect and appreciation by colleagues” for 17.91%
represent the most important factor for decision to
emigrate. “Being far from family members” was
considered by 64.18% of responders as an important
disadvantage of working abroad. As main conclusions, we
discover the factors which influence their decision to
emigrate represent the starting points on futures reforms in
educational and medical system in psychiatry.
Key words: residents: professional development,
workforce

INTRODUCTION Despite of different measures taken for reducing the

The Romanian physicians, and between them
psychiatrists, experienced an important rate of migration
in European countries after 2007, when Romania became
EU member. There were many concerns in media about the
“brain drain”, emigration of highly skilled health
professionals from less developed to developed countries
(1). The number of psychiatrists in Romania varied from
4.2/100 000 habitants in 2001, to 6.45/100000 (2),
respectively 5.97/100000 in 2014 (3), lower than other
European countries (9 psychiatrists/100 000) (2, 3). There
is important variance between the number of psychiatrists
in university centres (8.5/100000 in Bucharest,
8.3/100000 in Iasi and 5.4/100000 in Targu Mures) and
other regions (3.2/100000 in Covasna si Giurgiu).
The most popular countries for migration of Romanian
psychiatrists are France, Germany and the United
Kingdom (4) and in the last years also in other countries
(Sweden, Norway) which have active policies in recruiting
external personnel because of shortage in mental health
workforce (5).
The migration of residents and/or young specialists was a
major concern of Ministry of Health which elaborate a
strategy of human resources in health care system (3).
migration (a guarantee of a working place in regions with
low number of psychiatrists and increasing the salary) this
phenomenon continued. The official records show that
comparing 2007 vs. 2014, the number of both psychiatric
residents and young specialists (with less than 5 years of
professional experience) which migrate in EU countries
was doubled, and represent approximately 10% of total
number of trained professionals in the same period. The
numbers of specialists with more than 5 years of work
experience which migrate remain constant and very low
(1/year) (data from National Romanian College of
Physicians).
The job satisfaction depends not only on salary and
financial benefits but also on other factors as work–life
balance, facilities for employee comfort, work
facilitation, self-achievement and satisfaction, sense of
accomplishment, self-esteem, workload, work stress, job
security, responsibilities and decision making,
relationship with peers, work satisfaction, recognition,
role clarity, career growth, pride, etc. (6).
STUDY HYPOTHESES
Not only financial reasons motivate residents in
psychiatry to leave Romania. Identification of main factor

1
University of Medicine and Pharmacy Targu Mures, Romania
2
Institute of Psychotherapy and Personal Development, Targu Mures, Romania
3
University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
4
University Lucian Blaga Sibiu, Faculty of Medicine, Sibiu, Romania
5
University of Medicine and Pharmacy Iuliu Hatieganu Cluj Napoca
6
University Spiru Haret Bucharest, Faculty of Sociology-Psychology, Bucharest, Romania
7
University of Medicine and Pharmacy of Craiova, Romania
Correspondent author: Lecturer Mihail Cristian Pirlog, PhD, MPH,University of Medicine and Pharmacy of Craiova, Faculty of Medicine, Medical
Sociology Discipline
Petru Rares 2, Craiova, 200349, Dolj, Romania, Phone: 0040351443565 Fax: 0040251426688, Mobile: 0040722642561, E-mail:
mihai.pirlog@gmail.com
Received February 26, 2016, Revised February 29, 2016, Accepted March 17, 2016
27
Adriana Mihai, Maria Silvia Trandafir, Lavinia Duică, Alex Mihai, Cosmin Lungu, Anca Livia Chiriță, Mihail Cristian
Pîrlog: Romanian Psychiatric Residents' Opinion on Factors Which Influence Their Decision to Emigrate as Challenge
for Reforms in Educational and Medical System in Psychiatry
could be the starting point of a strategy of retaining
residents in psychiatry in country.
OBJECTIVES
To identify the factors related with residents in
psychiatry decision of remaining and work in Romania or
emigration in other EU countries and to do a prioritization
exercise of main factors. Secondary objective was to
provide some guidelines for elaborating a strategy to
reform the educational and medical system in psychiatry
starting from residents' opinion.
MATERIAL AND METHOD
Study setting
The study was conducted in Romania, an East
European country with a total land area of about 235 000
square km and a population of about 20 million people.
The selection criteria for entry into psychiatric training are
represented in Romania by a national exam where all
graduated medical students can participate. In order of the
grade obtained they could chose the preferred speciality.
The total number of psychiatric residents admitted in
training since 2011 is 512. There is a national psychiatric
training program and the training take place in 6 university
settings.
Methods
Because of the limited state of research, we have
chosen an explorative research strategy that combines
qualitative and quantitative methods. The study is a cross
sectional evaluation at national level, on a randomised
selected sample of Romanian psychiatric residents that
express their opinion the factors which influence decision
of migration in EU countries.
We randomly selected the target population of
residents in psychiatry. From the total number of residents
admitted in training in psychiatry (512) we excluded those
(98) which have to sustain the specialist exam in 2015. We
estimated a number of 414 residents in all years of
training. We calculate that the sample size has to be equal
with 80 residents for being quantitative and qualitative
representative with a precision of +5%. For national
randomisation, we divided the Romanian territory in 4
geographical regions and for each region we identified the
list of all residents in training. We contacted every fourth
on the list and plan an individual meeting for study
purpose. The study was a voluntary one, no incentives
were used. If one resident did not agree to participate, we
contacted the next in the list. The response rate was
86.75% (92 residents were contacted). If the resident
agreed to participate we used a self-administered, semi-
structured questionnaire, the data were collected in paper
and pen format. For ranking different factors, we used a
prioritisation exercise and ask each resident to quote from
1 to 9 each factor (1 less important, 9 the most important).
Statistical analysis
For obtaining the ranking score we have calculated the
average score allocated to each item. This score reflects
not only the position on each resident choice but also
depend on frequency of being chosen by different
residents. In calculation of percentage of residents which
consider on the first place a specific item, we excluded the
residents (16.25%) which did not express a clear choice
for first place in ranking and/or quoted with maximum
score – 9 – more than one item.
Ethical issues
The data were collected in confidential manner, no
28
identification data collected. We protect both individual
and institutional identity. The data will be presented only
on national and regional level for the same issue. The
study received the IRB approval at the local ethical
committee IPPD Institute of Psychotherapy and Personal
Development, Targu Mures, Romania.
RESULTS
There are no statistical differences between characteristics
of residents from different regions. In table 1, we
presented the sample demographical (age, gender, marital
status) and professional characteristics (as work
experience in years, workload -working hours/week,
night shifts/month, type of working place). All residents
who participated in the study live in urban area. Keeping
in mind that the period of 5 years represents the total
duration of psychiatric residency and in the last years the
number of residents that have been admitted in psychiatric
training increased gradually the average of 2.28 years of
work experience and that represent a characteristic of all
population of psychiatric residents. In our sample of
psychiatric residents population are more represented by
female residents (72.5%), average age 29.07 years old,
single, which work in hospital setting, similar amount of
working hours/week (35.71). The average salary of a
resident in psychiatry increased from 3600$/year in 2010
to 7800$/year in 2015.The work duration including the
night shift are stipulated at 35 hours/week. The majority of
residents in psychiatry work in university hospitals
(93.75%). We excluded from the table presentation the
working place items like community psychiatry, day
centres, and research or academic units because the
responders did not choose these answers.
Moreover, 75% of resident's answer that they consider the
possibility of working abroad in next years, but majority
of them (71.66%) intend to work abroad for a limited
period of time and only 28.33% of them intend to
emigrate. 5% of residents in psychiatry intend to change
the speciality or plan to choose another profession.
The factors evaluated were associated in 3 groups. (Table
2) First group of considered advantages for working
abroad highlight that even residents high quoted the better
salary (ranking score 6.8), better working (6.5) and living
conditions (6), more than one third (37.31%) of residents
ranked on first place better working conditions and
17.91% of them agreed that respect and appreciation by
colleagues is the first factor what motivate them to work
abroad.
The important role of nuclear and extended family in
Romanian tradition and culture is reflected also by
agreement of residents (64.18%) to consider “Being far
from family members” as an important disadvantage of
working abroad. Language difficulties, especially in a
speciality as psychiatry, have to be taken into
consideration, but are on first rank only for 13.45% of
subjects.
As proposed measures for improving actual situation of
psychiatric residents in Romania, the responders ranked
on the first place the need of improving postgraduate
education in psychiatry in general (34.33%) and in
psychotherapy in special (26.87%). The importance of
personal psychotherapy is underlined by residents which
quoted on 3rd places in list of measures need to be taken,
with 5.07 as cumulative rank score.
 Romanian Journal of Psychiatry, vol. XX, No.1, 2018

Table 1. The characteristics of the study sample

Characteristics Region 1 Region 2 Region 3 Region 4 National p

Gender
male 4 (30.76%) 9 (30.00%) 6 (27.27%) 3 (20.00%) 22 (27.50%) NS
female 9 (69.24%) 21 (70.00%) 16 (62.63%) 12 (80.00%) 58 (72.50%) NS
Average age 28.53 29.03 28.04 31.13 29.07 NS
Marital status
single 7 (53.84%) 24 (80.00%) 15 (68.18%) 6 (40.00%) 51 (63.75%) NS
married 6 (46.15%) 5 (16.66%) 7 (31.82%) 7 (46.66%) 25 (31.25%) NS
other 0 1 (4.54%) 0 2 (13.33%) 4 (5.00%) NS

Professional experience 2.30 2.46 2.40 1.73 2.28 NS

(years)
Workload 32.69 37.40 35.90 34.66 35.71 NS
(working hours/week)
Night shifts/month 1.92 1.16 2.36 1.66 1.71 NS
Psychiatric setting
Hospital 11 (84.61%) 28 (93.33%) 21 (95.45%) 15 (100%) 75 (93.75%) NS
Ambulatory 0 2 (6.66%) 1 (4.54%) 0 3 (3.75%) NS
Plus, another job 1 (7.69%) 0 0 0 1 (1.25%) NS
No answer 1 (7.69%) 0 0 0 1 (1.25%) NS

Table 2. Prioritizing exercise of factors which influence decision of work abroad

Items arranged by rank Ranking score The percentage of those
on each category (1 less important
–9 w ho chosethis item as most
most important) important
(1st place)
Advantages of w orking abroad
1 Better salary 6.8 16.41%
2 Better working conditions 6.65 37.31%
3 Better life conditions 6 11.94%
4 Better medical education 5.33 10.46%
5 Respect and appreciation by patients 3.57 4.47%
6 Respect and appreciation by colleagues 3.21 17.91%
7 Safety 2.85 1.49%
Disadvantages of w orking abroad
1 Being far from family 7.26 64.18%
2 Language difficulties 4.87 13.45%
3 Lack of friends 4.66 2.98%
4 Being an emigrant 4.25 7.46%
5 Lack of workplace for partner 3.05 7.46%
6 W orst life conditions 1.41 1.49%
7 Others 0.32 2.98%
Proposed changes inresident’seducation system
1 Better postgraduate training in psychiatry 5.96 34.33%
2 Higher salaries 5.37 16.44%
3 Access topersonal psychotherapy 5.07 1.49%
4 M ore training in psychotherapy 4.92 26.87%
5 M ore clinical supervisions 4.20 2.98%
6 Accommodation offered by hospitals 3.25 2.98%
7 M ore research involvement 3.21 7.46%
8 Regular assessment of professional
development 2.80 2.98%
and feed-back
9 M ore safety measures 2.60 2.98%
10 Less workload 0.55 1.49%
11 Others 0 0
29
Adriana Mihai, Maria Silvia Trandafir, Lavinia Duică, Alex Mihai, Cosmin Lungu, Anca Livia Chiriță, Mihail Cristian
Pîrlog: Romanian Psychiatric Residents' Opinion on Factors Which Influence Their Decision to Emigrate as Challenge
for Reforms in Educational and Medical System in Psychiatry
DISCUSSIONS
The items as better working conditions and better living
conditions which are highlighted by Romanian residents
are common with their colleagues from other low-income
countries (5-8). There are also items quoted as important
which are specific for Romanian population as respect and
appreciation by colleagues and the importance of family
relationships.
The Government and especially the Ministry of Health
were concerned about the mental health workforce'
deficits and about the residents' condition and as a
consequence of these facilitated some specific measures
(3). There were some measures concerning the availability
of workplace, the residents and specialists' salary, the
accommodation conditions for young adults, the number
of residents admitted in training and changes in national
training program.
For a better distribution of the mental health workforce, it
was organised for several times, a national exam for the
residents entry on psychiatric training associated with 5
years' work contract after the end of psychiatric training
on a specific working places (with high deficits in
qualified personnel). Even the residents participated with
enthusiasm to this exam; the measure had not expected
result because not all residents respect the contract after
the end of training period and the workforce deficit persist.
The salaries of residents and specialists increased
gradually in last decade, but still remain 2 - 6 times lower
than average salary in EU countries. There were states that
supported facilities for a bank loan for apartment
acquisitions for young adults.
There are several changes which have been done in
national psychiatric curriculum in order to improve the
quality of postgraduate psychiatric training as: increasing
recommended duration of training in psychotherapy,
rotation on different psychiatric sectors and sub-
specialities highly recommended, child and adolescent
psychiatry training, changes in total duration of training,
etc. The effect of these changes was very low in practice
because of the difficulties related with implementation of
these recommendations.
The future strategy of reforms in educational and medical
system in psychiatry has to implement the proposed
changes in practice and take measures which facilitate
changes in medical system simultaneously. If the clinical
and academic workload of trainers is high the time
allocated to mentoring and supervision of residents is low.
Any changes involved both academic and clinical setting.
The majority of residents have their experience only in
psychiatric hospitals because of the lack of access to
specific psychiatric settings (forensic, addiction, liaison
psychiatry, community psychiatry, day-care,
psychotherapeutic centres) which are present only in few
locations or in private sectors. The involvement of
different sectors of psychiatry in educational process
could be useful. For improving the workplace condition of
residents, the medical hospitals where residents work
have to be adapted not only to medical tasks but also to
educational process. The lack of space in hospitals,
absence of a room for residents was underlined as
important factor of stress and burnout in psychiatric
residents (9). Complex measures have to be taken.
The training in psychotherapy is a part of psychiatric
curriculum but there are only few places where is put in
practice because of the lack of trainers and of financial and
practical conditions for being done. The assessment of the
quality of a training program includes academic aspects,
30
working conditions and workplace assessment. The
evaluation of academic aspects includes the qualification
of trainers, an increasing number of trainees allocated to
one supervisor, structure of theoretical courses, cases
presentation, problem solving cases (10). It is important to
understand the real conditions of training and accessibility
to supervision in order to assess the workplace.
Supervision have to include clinical supervision,
individual supervision and supervision in psychotherapy.
Assessment of working conditions also includes
workload, numbers of duty hours, number of patients
examined by each trainee per day, presence of a trainees'
room and a consultation room (10). An international
independent team of assessment of training centres, as
UEMS (European Union of Medicines Specialists)
recommended, could be helpful in identification of
specific measures need it in each setting.
STUDY LIMITATIONSThe sample was randomly
selected at the national level and it is considered
representative for a group of Romanian residents in
psychiatry. Study limitation could be related with the fact
that the results could be influenced by the personality
traits of responders, which was not evaluated.
CONCLUSIONS
The factors which influence residents' decision to
emigrate represent the starting points on futures reforms in
educational and medical system in psychiatry.
Implications for Academic Leaders
-workplace assessment has to be part of training program
assessment
-the minimum training in psychotherapy is need it as part of
postgraduate psychiatric training
-postgraduate training could be improved with constant
evaluation of individualised resident educational needs
ACKNOWLEDGEMENTS
We are grateful to the Mr Chiurciu Catalin from National
Romanian College of Physicians, which contribute with the
official data collection.
DISCLOSURE
The authors have no competing interests to disclose.
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ORIGINAL ARTICLES

THE DELAY TO THE FIRST PSYCHIATRY

CONSULT IN TWO ACUTE INPATIENTS CLINICS
IN ROMANIA
Andreea R. Tirintica1, Mihail C. Pîrlog2, Dragoș O. Alexandru3, Traian Purnichi4,
Biatrice Mihălcuț5, Mariana Dragomir5, Laura Demijan5, Aurel Nireștean1,5,
1,6
Adriana Mihai
Abstract: Around 25% of adults experience a mental
illness in each year and approximately 60% received no
mental health care. There are still long delays between the
onset of symptoms and the first psychiatric consult and
treatment. Objective: To understand the pathway to care
and to determine the delay in seeking help for mental
health problems, considering sociodemographic variables
in patients admitted in two Romanian acute psychiatric
inpatients settings. Methods: Between May-August 2015,
WHO's Pathway Encounter Form was applied to 200
individuals, at their first admission, consecutively
hospitalized in acute psychiatry clinics from Targu Mures
and Craiova, Romania. Results: The profile of the
participants in this study was: woman in the sixth decade
of life, having an average economic status and without
psychiatric history, searching help for depressive
symptoms (by themselves or at the advice of the family),
mainly to a psychiatrist or a General Practitioner. The
average delay from the onset of symptoms to the first
psychiatry consult was 16 weeks. Only previous positive
personal history for MH problems and current diagnosis
had a high statistically significant influence on the moment
when subjects of our study decided to access the MH
services. Conclusions: A better knowledge and
understanding on the factors that influence people to seek
help in mental health problems would be useful for
improving the future organization of healthcare services
and programs. Keywords: psychiatric consult, onset of
symptoms, duration access

INTRODUCTION and it is important to underline that most people,

The latest data shows that 1 in 4 adults (approximately 450
million people worldwide) experiences a mental illness
each year (1, 2) and approximately 60% of them do not
received mental health care (MH) (3). Despite effective
treatments and universal health coverages in most of
countries, there are still long delays (sometimes even
decades) between the first appearance of symptoms and
the moment when people get help (4, 5). Different studies
tried to determine the duration of this delay, as the delay in
initial treatment has been recognized as an important
public health problem. (6) It seems that this delay varies
greatly, being determined by the patient's characteristics,
diagnosis, and healthcare system, the results of studies
realized in countries with a low and mid income, and
where health care system is under average, showed a
median delay of 10.5 weeks in Bangladesh (7), more than
2-5 years in South India (including in patient with for
schizophrenia) (8), more than 2 weeks in almost a third of
the cases in Malawi (9), 38 weeks in Ethiopia (10). the
duration of untreated psychosis (DUP) – an item studied in
various study around the world, because of the importance
of an early treatment – has also a median of 30.5 weeks.
(11)
Previous studies showed that one of the most important
factors influencing the delay in seeking help for mental
health problems is represented by the family (6, 12, 13),
especially older and less educated persons tend to be
reluctant to take psychotropic drugs (5). Other
incriminated factors are lack of knowledge and stigma
(16, 18, 20, 22), no formal education, joblessness and
other medical conditions (6, 10, 15), younger age of onset,
poor engagement with mental health programs and severe
symptoms (11), increasing illness severity or level of
disability (16), different labels such as “stress”,
“paranoid” and “shy” (23). According to an Australian
survey, media (internet, TV, newspapers etc.) represents a
common source of information about mental health and
links to help seeking (23).
There are some frequent pathways to mental health care,
worldwide: direct access (12) and indirect access (in a
third to three-quarters of cases) (21, 11), realized by GPs
(5, 7, 12, 14, 15, 16), general hospitals (20) and private
practitioners (12, 24), traditional and religious healers (7,
9, 10, 12, 17, 18, 19) – consulted even by patients with a
diagnosis of schizophrenia. Those indirect pathways
increase the delay to care (19), the frequency of accessing
emergency departments and, consequently, an increased
number of involuntary admissions. (13)
OBJECTIVES
Our aims were to identify the delay in accessing MH
services for the first time, to understand the pathway to
care and to describe the sociodemographic variables in

1
University of Medicine and Pharmacy Targu Mures, Romania, Gheorghe Marinescu street no 38, 540139 ; phone number 0040722406741, e-mail :
ralucatirintica@yahoo.com
2
Lecturer, 5th Department, Faculty of Medicine, University of Medicine Craiova, Romania
3
Lecturer, 2nd Department, Faculty of Medicine, University of Medicine Craiova, Romania
4
MD, PhD Student, Doctoral School, University of Medicine and Pharmacy Craiova, Romania
5
MD, PhD, University Psychiatry County Clinic II Targu Mures
6
MD, PhD, IPPD Institute of Psychotherapy and Personal Development, Mures, Romania
Received November 19, 2015, Revised January 11, 2016, Accepted January 31, 2016
31
Andreea R. Tirintica, Mihail C. Pîrlog, Dragoș O. Alexandru, Traian Purnichi, Biatrice Mihălcuț, Mariana Dragomir,
Laura Demijan, Aurel Nireștean, Adriana Mihai: The Delay to the First Psychiatry Consult in Two Acute Inpatients
Clinics in Romania
patients who seek help for MH problems, in two clinics for participants were women, out of which 83% in the sixth
acute psychiatric inpatients in our country. decade of life. Most of the participants declared
MATERIAL AND METHODS themselves having an average economic status (83% of
Our study included 200 adult patients at their first cases), with only 9.5% and 7.5% declaring themselves
psychiatry consult, consecutively admitted in two acute poor and respectively, having a high economic status.
psychiatry university clinics in Romania (100 patients in Also, 63% of the patients had no history of MH problems.
Targu Mures and respectively 100 in Craiova), during a The first decision to seek help for the MH problem was
period of approximately 3 months (May-August 2015), suggested in half of the cases by the patients themselves,
until the targeted number of 100 patients for each setting closely followed by the family (40.5% of the cases). Only
was achieved. 8.5% of the consultations were suggested by a specialist
In the study sample were included all patients who met the doctors and 1% by the patient's GPs. The first consult was
following criteria: done, in the majority of cases, by a psychiatrist, followed
·Adults, age over 18 years; by a GP, respectively Emergency Department's
·New cases, who have never been admitted in a psychiatry specialists. (Figure 1)
clinic before;
·Able to understand the purpose and design of the study
(were excluded the patients with delirium and severe
cognitive impairment, according to a previous clinical
evaluation made by a psychiatrist and the results of Mini
Mental State Examination - MMSE);
·Voluntary accept to participate in the study, by giving a
verbal accept and signing a written informed consent.
The procedure was explained to the patients and the
volunteers were enrolled in the study. After the verbal
approval to participate, each patient signed a written
informed consent, where it was clearly stated that the Fig 1. Healthcare providers who offered first consult for mental
participation in this study has no influence on the access to health problems
care (or on the treatment received), the questionnaires
respect the confidentiality of the participants, and no The reasons for the first consult were mostly depressive
payment will be offered to the participants. We didn't used symptoms (64.5%), followed by sleep disorders (19.5%),
any recruitment material and the participants were free to anxiety and panic attacks (16.5%), psychotic symptoms
refuse the study at any moment. (15.0%, out of which 3.5% had suicidal thoughts!), and
After signing the informed consent, each participant was somatic complaints (11.5%). Most of the patients seek
asked about the delay to the first psychiatry consult, in an help for two or more symptoms.
interview following a translated version of the WHO The treatment received in the majority of cases was
Pathway Encounter Form, which collects data about: antidepressant drugs (66.0%), benzodiazepines (36.0%),
·Characteristics of the patient: age, gender, marital and antipsychotics (18.5%) and vitamins (18%). Our study
economic status, history of psychiatric diagnosis; revealed that benzodiazepines are very often prescribed as
·The first decision to seek help for his/her MH problem: the first intention in MH problems. For some patients were
with who?, how long ago?, who suggested the first consult prescribed associations of psychotropic drugs.
and why?, when the first symptoms occurred?, treatment The categories of diagnosis were the following: 66.5%
received, the duration of the delay; affective disorders, 10% psychotic disorders, 10% drug
·The main category of diagnosis of the patient and related disorders (mostly alcohol dependencies), 6.5%
associated health problems. somatic disorders, 5.5% diagnosis of anxiety, 1%
The average duration for the interview was 10 minutes for personality disorders and 0.5% cognitive disorders. Few
each participant. Data was filled in by the authors for each patients had more than one diagnosis.
patient, who received a number from 1 to 100, in order to
respect the confidentiality of the participants.
The approval to use the WHO Pathway Encounter Form
questionnaire was obtained, and the study was approved
by the local ethical committees.
RESULTS
The sample of 200 patients was unequal regarding the
characteristics of participants. The majority of patients
were women (77.5%, comparing with only 22.5% men) in
the sixth decade of life (50 – 59 years), 75.5% were
married, 9% single and 9% widows, and the rest were
divorced (6.5%).
Fig 2. The delay between onset of symptoms and the first
According to their age, 6.5% of the participants were 18-
psychiatric consult (weeks)
29 years old, 7% were 30-39 years, 7% 40 to 49 years, and
the majority (54%) were in the sixth decade, while 15.5% The delay from the onset of the symptoms to the first
were older than 60 years. An important difference between psychiatric consult varies greatly from one patient to
the two sites was noticed: in Craiova, 90% of the another, with a median delay of 16 weeks (Figure 2).

32
 Romanian Journal of Psychiatry, vol. XX, No.1, 2018

D u r a tio n o f d e la y G en der p (C h i
sq u a re)
W o m en M en
< 1 m o n th 3 9 ,3 5 3 3 ,3 3
1-6 m o n t h s 2 2 ,5 8 2 6 ,6 7 0 ,1 3 5
6-1 2 m o n t h s 2 5 ,1 6 1 3 ,3 3
1-5 y e a r s 9 ,0 3 2 0 ,0 0
> 5 years 3 ,8 7 6 ,6 7
D u r a tio n o f d e la y M a r ita l s ta tu s
m a r r ie d s in g le w id o w e d iv o r c e d
< 1 m o n th 3 7 ,7 5 3 3 ,3 3 5 5 ,5 6 2 3 ,0 8
1-6 m o n t h s 2 4 ,5 0 1 6 ,6 7 1 6 ,6 7 3 0 ,7 7 0 ,7 7 2
6-1 2 m o n t h s 2 3 ,1 8 2 2 ,2 2 1 6 ,6 7 2 3 ,0 8
1-5 y e a r s 9 ,9 3 1 6 ,6 7 1 1 ,1 1 2 3 ,0 8
> 5 years 4 ,6 4 1 1 ,1 1 0 ,0 0 0 ,0 0
D u r a tio n o f d e la y P e r s o n a l h is to r y o f M H p r o b le m s
no yes
< 1 m o n th 4 9 ,2 1 8 ,4 3
1-6 m o n t h s 2 2 ,2 2 1 1 ,4 5 3 , 5 1 8 5 -0
3 5E
6-1 2 m o n t h s 1 3 ,4 9 1 6 ,8 7
1-5 y e a r s 9 ,5 2 6 ,6 3
> 5 years 5 ,5 6 1 ,2 0
D u r a tio n o f d e la y E c o n o m ic a l s ta tu s
h ig h average poor
< 1 m o n th 3 3 ,3 3 3 9 ,1 6 3 1 ,5 8
1-6 m o n t h s 3 3 ,3 3 2 2 ,2 9 2 6 ,3 2 0 ,2 8 9
6-1 2 m o n t h s 6 ,6 7 2 4 ,7 0 1 5 ,7 9
1-5 y e a r s 2 6 ,6 7 9 ,0 4 2 1 ,0 5
> 5 years 0 ,0 0 4 ,8 2 5 ,2 6
D u r a tio n o f d e la y C u r r e n t d ia g n o s is (I C D 10)
F 0 0- F 0 9 F 1 0– F 1 9 F 20 F 3 0– F 4 0–
– F 39 F 49
F 29 -0 7
< 1 m o n th 9 2 ,8 6 1 5 ,0 0 4 0 ,0 0 3 7 ,5 9 1 8 ,1 8 7 ,9 1 7 4 5 E
1-6 m o n t h s 0 ,0 0 2 0 ,0 0 2 0 ,0 0 2 5 ,5 6 3 6 ,3 6
6-1 2 m o n t h s 0 ,0 0 1 5 ,0 0 0 ,0 0 2 7 ,0 7 4 5 ,4 5
1-5 y e a r s 7 ,1 4 3 5 ,0 0 3 0 ,0 0 6 ,7 7 0 ,0 0
> 5 years 0 ,0 0 1 5 ,0 0 1 0 ,0 0 3 ,0 1 0 ,0 0
Table 1. Factors influencing duration of delay

The longest delay recorded was approximately 20 years
and the symptoms described by the subjects were mostly
somatic. As it could be observed in the Table I, statistical
analysis (Chi square test) showed that out of all factors
considered to have an influence on the delay to search for
professional mental health care, only previous positive
personal history for the MH problems (p<0.001),
respectively current diagnosis (p<0.001) had a high
statistically significant influence to the moment when
subjects of our study decided to access the MH services.
DISCUSSIONS
The high prevalence of women aged between 50-59 years
had no evident explanations. All patients live in the
defined area, which could suggest that distance to MH
services is important in accessing health care.
The average economic status is common for a South-
eastern European country and the absence of relevant MH
history was expected in the majority of cases, because
patients with psychiatric diagnosis usually have at least
one psychiatry admission in a certain moment in their life.
An important result for understanding the pathway to care
is the importance of family in seeking help for MH
problems. Also, patients asking help for themselves
suggest either a good awareness about MH diagnosis and
available treatments, based on previous experience, or it
could be biased by the high prevalence of histrionic traits
in women, who are majority in our study. Further
investigations would be necessary, in order to elucidate
the small numbers of referrals suggested by GPs and
specialist doctors. The importance of the GPs in the

33
Andreea R. Tirintica, Mihail C. Pîrlog, Dragoș O. Alexandru, Traian Purnichi, Biatrice Mihălcuț, Mariana Dragomir,
Laura Demijan, Aurel Nireștean, Adriana Mihai: The Delay to the First Psychiatry Consult in Two Acute Inpatients
Clinics in Romania
pathway to MH care is confirmed in our study, as we
expected after the previous experiences described in the
literature.
Results' repartition regarding the psychiatric symptoms
which determined the participants in the study to seek
help, seem to follow the epidemiological evidence, with a
greater prevalence of depressive symptoms and
consequently, of affective disorders diagnosis, this group
of symptoms having a significant influence on our study
sample.
An alarming result is the frequent prescription of
benzodiazepines in the first psychiatric consult, but this
result could be obtained due to the specific (egg. more
severe) psychopathology referred in psychiatric acute
hospitals.
The median delay of 16 weeks seems to be aligned to other
international studies' results. However, there are
important differences in the delay (sometimes decades)
from patient to patient.
There is no clear evidence regarding the factors that could
influence the delay and the pathway to MH care, but few
suppositions were already made. Further investigations
are still needed, in order to find adequate modalities for
improving the access to care for people facing MH
problems.
CONCLUSIONS
Knowing the delay from the onset of the symptoms to the
first psychiatry consult, as well as understanding the
factors influencing people to seek help in MH problems
would be useful for improving the future organization of
MH services and for the development of different MH
programs.
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***
ORIGINAL ARTICLES
CORRELATIONS BETWEEN THE AFFECTIVE
RESPONSE AND AGGRESSIVENESS LEVEL AT
PATIENTS WITH PSYCHOTIC DISORDERS
Ionela N Cotos1, Karol J Wild2
Abstract
Schizophrenia is a mental disorder in which positive
symptoms (hallucinations, delusions, conceptual
disorganization and behavioral), negative symptoms,
cognitive dysfunction and improper emotional responses
are considered cardinal symptoms.
Hostility and aggression are common in major psychiatric
disorders such as schizophrenia, schizoaffective disorder
and bipolar affective disorders, aggressive behavior
constituting a diagnostic criterion for certain personality
disorders: antisocial disorder and borderline disorder.
Emotional expressiveness may cause malfunctioning,
verbal and physical aggression.
Material and method:
The preliminary study was conducted on a total of 26
patients diagnosed with schizophrenia and schizoaffective
disorder according to DSM-V operational criteria (2013)
and ICD 10 (1992). In the study group were predominantly
male, urban areas, the average age being 37 years old;
most patients had secondary education.
We applied: scale PANSS with subscales PANSS positive
PANSS negative and PANSS general scale YMRS, HAM-D,
HAM-A and questionnaire aggression Bush & Perri
Introduction
Schizophrenia is a mental disorder in which
positive symptoms (hallucinations, delusions, conceptual
disorganization, and behavior), negative symptoms (flat
emotion, apathy, anhedonia, inappropriate emotional
responses) and cognitive dysfunction are considered
cardinal symptoms. (1)
According to current clinical data, the term
"positive" describe the content of a symptom which
represents an exaggeration of a function or behavior
"which does not occur in normal people." Therefore, its
contents can be described as florid and measurable. On the
other hand, a "negative" symptom describes a deficiency
or absence of a function or a signal, status or "behavior
which does not occur in normal people" (2)
According to the Clérambault, a negative
symptom is a "deficit" or "inhibition". (3)
Cognitive dysfunction in schizophrenia appear
defined as decreased ability of abstraction and executive
functions and by default that, decrease the ability of
understanding and processing the information.
Hostility and aggression are common in major
1
Assist. univ., MD, PhD student., West University "Vasile Goldis" Arad, Department of Psychiatry, No. 86 Liviu Rebreanu street, Arad, Tel:
0749201866, Email: ionela.cotos@yahoo.com
2
Assist. univ. PhD student, West University "Vasile Goldis" Arad, Department of Psycho-Social and Human Sciences, No. 15 Mihai Eminescu street,
Arad, Tel: 0766587768, Email: karol.wild@wildassociates.ro
Received December 3, 2015, Revised December 11, 2015, Accepted December 22, 2015
(1992) with four subscales (physical aggression and
verbal, anger, hostility).
The objective of this study was to establish correlations
between the level of aggression and emotional response
PANSS negative subscale scores determined by, YMRS,
HAM-D, HAM-A.
Results and discussions:
Applying regression methods multiline and correlations
between variables were revealed significant positive
relationships between YMRS scale values, namely (a) total
score of aggression questionnaire (r = .428, p = .029, (b)
Physical Aggression Factor ( r = .593, p = .001), and (c)
factor Anger (r = .418, p = .034). The items of the scale
PANSS negative subscale correlated significantly negative
with the Anger factor in the aggression questionnaire (r = -
0.440, p = .024).
Conclusions:
Aggression and anger are positively correlated with manic
symptoms and negative with affective flattening, apathy. In
conclusion, physical aggression can be predicted by
YMRS score or PANSS negative score.
Keywords: schizophrenia, aggression, anger, negative
symptoms
psychiatric disorders (schizophrenia, schizoaffective
disorder, bipolar affective disorders), aggressive behavior
constituting a diagnostic criterion for certain personality
disorders: antisocial disorder and borderline disorder.
Aggression is most common in young men and in people
with a history of violence, impulsivity, substance abuse
and nonadherence to treatment. (4)
Aggression can be defined as intent to injure
another person physically or psychologically, with the
potential to induce violence when is uncontrolled (5).
In 2000 Arseneault et al. (6) demonstrate in their
study that in patients with psychosis the probability to
commit violent acts is 4 times higher than in the general
population, while patients suffering from schizophrenia
are responsible for about 10% of significant acts of
aggression; they are defined as "attacks on a person or
property of another or self-mutilation, with a deliberate
intention to destroy."
In schizophrenia, aggression it is heterogeneous
in terms of etiology and clinical, being directly linked to
hallucinations and psychotic symptoms, delusions and / or
conceptual and behavior disorganization (7). The
35
Ionela N Cotos, Karol J Wild: Correlations Between the Affective Response and Aggressiveness Level at Patients with
Psychotic Disorders

incidence of aggression among patients with The results are consistent with specialty
schizophrenia hospitalized was related to the level of literature, namely that the negative symptoms with a
aggression and anxiety at admission (8), aggression and marked decrease emotional resonance capacity (PANSS-
violence during previous hospitalizations (9), positive N) suggests a low level of anger. (Chart 1). Similar data
symptoms (10), paranoid type of schizophrenia (11), were recorded in the study CATIE (Clinical Antipsychotic
hospital environmental factors (12.13), neurological Trials of Intervention Effectiveness, 2003) that were
disorders (14) and noncompliant treatment (15). In data evaluated over a period of six months, correlations
published in 2006 by Mojtabai, it was shown that 5.1% of between violent behavior, negative symptoms and
38 132 adults showed psychotic symptoms are associated positive symptoms using "The MacArthur Comunity
with a fivefold increase in the risk of aggression (16). Interview Violence "(25). Variables correlated with
In the study led by Soyka in 2002, data regarding minor violence were younger age, female gender, low
the prevalence of aggression and violence in individuals socioeconomic level, shared residence with family or
diagnosed with schizophrenia vary greatly depending on another person, increased score on the positive symptoms
the time of conceptualization and evaluation of it, but PANSS subscale. Five items in the PANSS scale, subscale
Sanders et al. (2000) showed that the risk of aggression for positive symptoms have been associated with severe
and violence is often overlooked even in patients with violence (hostility, suspiciousness, persecution,
potentially aggressive cert. (17.18). hallucinatory behavior, grandiosity, excitability). PANSS
negative subscale was correlated with the reduction of
The main objective of this preliminary study was to severe violence (26).
determine correlations between the level of In our research, the existence of multiple
aggressiveness and emotional response determined by correlations between mania, aggression and negative
PANSS negative subscale scores, YMRS, HAM-D, symptoms required in order to increase data accuracy,
HAM-A. application regression analysis multiline with
independent variables (YMRS and PANSS-N) and
Material and method: dependent variables (subscales of the questionnaire
The research was performed on 26 patients aggressiveness).
diagnosed with schizophrenia and schizoaffective Preliminary results obtained showed that anger
disorder. The diagnosis was established according to and negative symptoms contribute in proportion of 27.1%
DSM-V (4) and ICD-10 (1). The group consisted mostly in causing anger (F (2,23) = 5.64, p = .01) and in
of men from urban areas, with an average age of 37, most proportion of 39.4% in the occurrence of aggression
subjects with secondary education. It were applied the physical (F (2,23) = 9.119, p = .01). (Table 2)
PANSS scale (19) with subscales PANSS positive Our study didn't show statistically significant
PANSS negative and PANSS general scale, YMRS correlations between aggression questionnaire score and
scale(20), HAM-D scale (21), HAM-A scale (22) and HAM-D and HAM-A scale score.
aggression questionnaire Bush & Perri (1992) ( 23) with
Correlations
four subscales (physical and verbal aggression, anger, PANSS YMRS HAM- HAM-
hostility). NEGATIV D A
YRMS scale application in schizophrenia has Pearson Correlation 1 -.120 -.328 -.328
PANSS
been suggested by the fact that emotional expressiveness NEGATIV E
Sig. (2 -tailed) .560 .102 .102
may contribute to aggression and violence as behavior N 26 26 26 26
Pearson Correlation -.120 1 -.304 -.218
(24), and was partially confirmed by the preliminary study YMRS Sig. (2 -tailed) .560 .131 .285
conducted by Vaina et al (2014). N 26 26 26 26
Pearson Correlation -.328 -.304 1 .842 **
Results and discussions: HAM-D Sig. (2 -tailed) .102 .131 .000
The application of the scales mentioned above N 26 26 26 26
Pearson Correlation -.328 -.218 .842 ** 1
reveals a significant positive correlation between mania HAM-A Sig. (2 -tailed) .102 .285 .000
(YRMS score) and total score of the questionnaire N 26 26 26 26
aggression (r = .428, p = .029) between mania and physical AGGRESSI Pearson Correlation -.387 .428 * -.003 .010
aggression factor (r = .593, p = .001) and between mania ON Sig. (2 -tailed) .051 .029 .988 .961
QUESTION
and anger factor (r = .418, p = .034). (table 1) AIRE
N 26 26 26 26
The results were similar to those in the PHYSICAL Pearson Correlation -.370 .593 ** -.025 .024
preliminary study conducted by Vaina et al. (2014) in AGGRESSI Sig. (2 -tailed) .063 .001 .903 .909
which was used the original test SAFFIMAP investigating ON
N 26 26 26 26
the effect of subliminal images with aggressive content in FACTOR
VERBAL Pearson Correlation -.380 .097 .320 .329
patients with disorders from the psychotic spectrum (24). AGGRESSI Sig. (2 -tailed) .055 .636 .111 .101
The correlations obtained indicates that the ON
N 26 26 26 26
presence of a manic symptomatology type with severe FACTOR
intensity is frequently associated with physically Pearson Correlation -.440 * .418 * -.103 -.134
ANGER
Sig. (2 -tailed) .024 .034 .616 .515
aggressive behavior, respectively with heightened anger. FACTOR
N 26 26 26 26
(Charts 2 and 3) Pearson Correlation -.184 .395 * -.111 -.085
HOSTILIT
Our preliminary study shows a significant Y FACTOR
Sig. (2 -tailed) .369 .046 .590 .678
negative correlation between negative items of PANSS N 26 26 26 26
scale (PANSS-N) with the anger factor subscale of the *. Correlation is significant at the 0.05 level (2 -tailed).
**. Correlation is significant at the 0.01 level (2 -tailed).
aggression questionnaire (r = -0.440, p = .024).
Table 1. Correlations between the study variables
36
 Romanian Journal of Psychiatry, vol. XX, No.1, 2018

Figure 1. Correlations between PANSS negative subscale and

Anger Factor subscale Figure 3. Correlation between YMRS scale score and Physical
Aggression Factor subscale score

Conclusions:
Aggression, respectively anger factor are
positively correlated with mania and negative correlated
with affective flattening, apathy, so physical aggression
may be predictable based on YMRS score or PANSS
negative subscale score.
The small number of patients tested (26) is the
limitation of this preliminary study and we consider for
future research a greater number of subjects (60), also, we
want to test them longitudinally, at admission and after
periods of treatment (3 weeks, 6 weeks and 6 months,
respectively) as well as comparative analysis with a group
of normal subjects.

Figure 2. Correlation between YMRS scale score and REMINDER: The authors have also contributed to create
aggression questionnaire score the article, having equal rights. All authors approved the
final version of this article.
Dependent Variabile = ANGER FACTOR CONFLICTS OF INTEREST: The authors do not report
Method: Multiple Linear Regression any conflict of interest in the implementation of this
Predictor Coef. StError T P article.
Intercept 27.922 4.910 5.687 0.000 **
ABBREVIATIONS:
YMRS 0.216 .100 2.154 0.042 * 1. DSM-V-TR - Manual of Diagnostic and statistical
classification of mental disorders
PANSS -.470 .204 -2.30 0.031* 2. ICD-10- International Classification of diseases and
Neg health problems
R-squared: 0.329, Adjusted-squared:
R 0.271 , F(2, 23) 3. PANSS- The positive and negative syndrome scale for
= 5.64, p= 0.01 schizophrenia
Note. YMRS = …………; PANSS Neg. = ……..:.
Signif. codes: ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1
4. PANSS-N - PANSS negative subscale items
Dependent Variabil e = PHYSICAL AGGRESSION 5. HAM-A -Hamilton anxiety rating scale
FACTOR 6. HAM-D- Hamilton Depression Rating Scale
Method: Multiple Linear Regression 7. YRMS- Young Mania Rating Scale
Predictor Coef. StError T P
Intercept 31.279 6.867 4.555 0.000 ** References:
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YMRS .497 .140 3.550 0.002 * behavioral disorders. Diagnostic Criteria for Research Geneva,1992.
2.Andreas M, Andreasen NC, Tsuang MT. Negative versus Positive
PANSS -.552 .286 -1.932 0.066 Schizophrenia, Springer Science&Business Media, 2012
Neg 3.De Clérambault GG. Œuvres psychiatriques. Frénésie, Paris, 1987
R-squared: 0.442, Adjusted-squared:
R 0.394 , F(2, 23) = 4.Association, American Psychiatric. Diagnostic and Statistical Manual
9.119, p= 0.01 of Mental Disorders, Fifth Edition (DSM-5). Washington D.C.:
American Psychiatric Association, 2013.
Note. YMRS = …………; PANSS Neg. = ……..:.
5.Szeszko PR, Am J Psychiat 171:9, September 2014 Editorial
Signif. codes: ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1
6.Arseneault L et al, Mental Disorders and Violence in a Total Birth
Table 2. Correlations between independent variables (YMRS, Cohort, Arch Gen Psychiatry. 2000;57(10):979-986
7.Volavka J. Violence in schizophrenia and bipolar disorder; Psychiatria
PANSS-N) and dependent variables (anger factor and physical
Danubia, 2013; Vol. 25, No. 1, pp. 24-33 – Medicinskanaklada- Zagreb,
aggression factor)

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Psychotic Disorders
Croatia
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assaultiveness in psychiatric inpatients: A pilot study. Hospital and
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evaluation of aggression in psychiatric patients. Journal of Nervous and
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on an acute psychiatric ward: A study of associated factors. The British J
Psychiat, 1990, 156:846-852.
14.Krakowski MI, Convit A, Jaeger J, Lin S, Volavka J. Neurological
impairment in violent schizophrenic inpatients. Am J Psych, 1989,
146:849-853.
15.Calcedo BAL, Calcedo OA. Violence and paranoid schizophrenia.
International Journal of Law and Psychiatry, 1994, 17:253-263
16.Mojtabai R. Psychotic-like experiences and interpersonal violence in
the general population. Soc. Psychiatry Psychiatr. Epidemiol. 2006, 40,
1–8.
17.Soyka M. Aggression in schizophrenia: assessment and prevalence,
The British J Psychiat 2002, 180 (3) 278-279
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18.Sanders J, Milne S, Browne P et al. Assessment of aggression in
psychiatry admissions: semistructured interview and case note survey.
The British J Psychiat 2000, 320, 1112.
19.Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome
scale (PANSS) for schizophrenia. Schizophr Bull. 1987; 13: 261-
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20.Young RC, Biggs JT, Ziegler VE, Meyer DA. Young Mania Rating
Scale. In: Handbook of Psychiatric Measures. Washington, DC:
American Psychiatric Association; 2000;540-542.
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Psychiatry 1960; Hamilton Depression Rating Scale (HDRS).
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26.Petris A, Evaluarea şi predicţia riscului pentru violenţă la populaţia
forensică psihiatrică. Violenţa în schizofrenie, 2012
***
CLINICAL CASE
HIGH CREATINE KINASE IN A PSYCHIATRIC
PATIENT WITHOUT ANTIPSYCHOTIC
TREATMENT
Ana-Anca Talașman¹, Alexandra Dolfi2, Dan Prelipceanu1
Abstract: In psychiatry, high creatine kinase (CK) levels
and leukocytosis are known to be associated with
neuroleptic malignant syndrome (NMS), (1,2) but there are
many other causes that can present with an elevated serum
level of this enzyme. CK is affected by age, gender, race,
but also by many other diseases such as myocardial
infarction (elevated CK-MB fraction), neuromuscular
diseases, periodic paralyses, muscular traumas and high
physical effort, elevated CK being a sign of
rhabdomyolysis. We present a case of a 34-year- old male
with spastic tetraplegia, mental retardation and alcohol
dependence admitted in Alexandru Obregia psychiatry
hospital in Bucharest, who presented a very elevated CK
level (over 28000 units) at admission although no
neuroleptic treatment was administered.
Key words: elevated creatine kinase, spastic tetraplegia,
alcoholism.
BACKGROUND: Creatine kinase is a nonspecific
parameter, an elevated level indicating rhabdomyolysis. In
psychiatry, high creatine kinase (CK) levels and
leukocytosis are known to be associated with neuroleptic
malignant syndrome (NMS), (1) but there are many other
causes that can present with an elevated serum level of this
enzyme. CK is affected by age, gender, race, but also by
many other diseases such as myocardial infarction
(elevated CK-MB fraction), neuromuscular diseases,
periodic paralyses, muscular traumas and high physical
effort. High CK levels were also shown in marathon
runners (over 4000 units) post-race. (2,5)
We present the intriguing case of a 34-year-old male
admitted in Alexandru Obregia psychiatry hospital on
21.04.2017 for alcohol withdrawal. He had a long history
of chronic alcohol abuse and was suffering from epilepsy
with generalized tonic-clonic seizures on the background
of spastic tetraplegia and mental retardation due to
perinatal cerebral hypoxia. He presented a very elevated
CK level (over 28 000 units) after admission, although he
wasn't under any neuroleptic treatment and had no history
of trauma, physical effort or other diseases. It proved to be
a very intriguing case for us, because the other blood
parameters weren't highly modified, except liver enzymes.
He was hospitalized for 3 weeks, during 21.04.2017 and
19.05.2017, and was discharged with normal blood
parameters and CK level within physiologic limits.
HISTORY: The patient is brought to the on call room on
¹MD, PhD, Clinical Hospital of Psychiatry “Prof. Dr. Al. Obregia” Bucharest, No.10 Berceni Street, email: anaanca@yahoo.com
2
Resident in Psychiatry, Clinical Hospital of Psychiatry “Prof. Dr. Al. Obregia”, Bucharest, email: dolfialexandra@gmail.com
Received November 1, 2015, Revised November 16, 2015, Accepted January 9, 2017
Rezumat: În psihiatrie, un nivel crescut al creatin kinazei
alaturi de leucocitoza sunt asociate cu sindromul
neuroleptic malign. (2,3,4) Există însă și multe alte cauze
care pot crește nivelul seric al acestei enzime, aceasta fiind
influențată de vârstă, sex și rasă și crescută în infarctul
miocardic (fracțiunea CK-MB), bolile neuromulsculare,
paraliziile periodice, traumatismele musculare și efortul
fizic ridicat, nivelul crescut al CK fiind un indicator al
rabdomiolizei. Prezentăm cazul unui bărbat de 31 de ani
cu tetraplegie spastică, retard mental și dependență
etanolică, internat în spitalul Alexandru Obregia
București, care a prezentat un nivel foarte ridicat al CK
(peste 28 000 unități) la internare, cu toate că nu a primit
tratament neuroleptic.
Cuvinte cheie: creatin kinază, tetraplegie spastică,
dependență etanolica.
21.04.2017 at 8:30 pm by his mother for irritability,
irascibility, emotional lability, auto-aggressive tendencies,
verbal and physical hetero-aggressive outbursts towards
his mother, psychomotor agitation and tremor of
extremities in the context of abusive alcohol consumption
(beer and brandy) and treatment non compliance (he was
occasionally administered 1 tablet of 10 mg Diazepam by
his mother).
The patient has been consuming alcohol daily for over 10
years with many admissions in the past for alcohol
withdrawal symptoms. He is a smoker (1 and a half pack
per day), suffering from epilepsy with tonic-clonic
seizures and spastic tetraplegia since birth, due to perinatal
cerebral hypoxia, and slight mental retardation (IQ=60).
He was living with his mother, receiving a disability
pension since 1995, never worked, not married, without
children.
The physical examination at admission, in the on call room
shows a conscious underweight patient with erythematous
face and palms, scleral jaundice, diaphoresis, tremor of
extremities, normal heart and lung sounds, tachycardia
(120 bpm), arterial pressure of 150/100 mmHg, no pain at
abdominal palpation, liver 2 cm below inferior costal
margin and exaggerated deep tendon reflexes in all four
limbs (spasticity).
PSYCHIATRIC AND PHYSICAL EXAMINATION: was
performed on 24.04.2017 when the patient arrived on the
ward. It revealed a conscious and partially co operant


39
Ana-anca Talașman, Alexandra Dolfi, Dan Prelipceanu: High Creatine Kinase in a Psychiatric Patient Without
Antipsychotic Treatment

patient, oriented in time and space, autopsychic and
allopsychic oriented, visual and psychic contact difficult
to start and maintain, stereotypical mimic and gesture,
expressive asymmetric facies, spontaneous and voluntary
hypoprosexia, no affirmative perception disturbances,
retro-grade amnesia, dysarthria, bradylalia, slow rate of
speech, absent spontaneous speech. Autolytic ideation
and delirium were absent. His hygiene was poor, he
presented low appetite, mixed insomnias and impaired
insight.
The physical examination at this date showed generalized
tremor, oro-facial dyskinesia, scleral jaundice,
tachycardia (100 bpm), low blood pressure (88/58
mmHg), dry skin, no fever, no signs of meningeal
irritation, no edema, normal heart and lung sounds.
PARA CLINICAL EXAMINATION: first blood tests
were taken on 24.04.2017. No earlier tests were made
because the patient was admitted on a Friday night and
spent all weekend in the on call room in a stable state, the
hospital laboratory being closed during weekends. He was
transferred in the ward on April 24. The evolution of the
abnormal blood parameters is shown in the table 1 below,
throughout all hospitalization period. The patient
presented very high creatine kinase (28597 units), which
return to normal after several days, on 08.05.2017. His
liver enzymes were also increased, with very high GGT at
admission (1359.98 units), abnormal creatinin and urea
and leukocytosis with high neutrophils count. On the next
day (25.04) his potassium decreased to 3.2 mmol/L, the
patient presenting also low red blood cells count with low
hemoglobin. All these parameters normalized close to
discharge, all returning to normal on 08.05.2017, the
patient being discharged on 19.05.2017.
On 26.04.2017 the patient presents hematuria. Urinary
analysis show some abnormal parameters: Urinary
glucose 150 mg/dl, urobilinogen 8 mg/dl, red blood cells
50Ery/ul, urinary sediment: frequent red blood cells,
ammonia magnesium phosphate crystals abundant. The
internal medicine consult recommends glyoxylate
hemoglobin, which was normal and repeating of the
urinary analysis in two days. On 27.04.2017 the urinary
parameters were normal, except for a higher urobilinogen
of 8 mg/dl.
Both EKG and chest X-Ray were normal, patient didn't
present any fever. The internal medicine consults
recommended iv hydration (2500 ml per day) and hepatic
protection and sylimarin in high dose (1000mg/day) in
association with the anti-epileptic treatment and
benzodiazepines. No neuroleptic treatment was
administered. Two neurological exams were performed,
with no abnormal modifications except those due to
spastic tetraplegia.

Blood parameter 24.04 25.04 26.04 27.04 28.04 02.05 03.05 08.05
CK (U/l) 28597 15961 9101 7010 4406 491 315 163
GGT (U/l) 1359. 1012. 783.7 - - 533.9 360.72
98 21
TGO (U/l) 818 479 400 - - 90 65
TGP (U/l) 307 213 160 - - 145 100
Creatinin 2.12 0.85 0.5 - - 0.57 0.68
(mg/dl)
K+ (mmol/L) 3.8 3.2 3.2 - - 4.2 4.9
Urea 139 54 26 - - 14 17
(mg/dl)
WBC 13.34 12.02 - - - 11.03 8.94 10.03
(x103/uL)
Neu (%) 82.7 82.6 - - - 53.6 50.7 55.1
RBC 4.44 3.74 - - - 3.53 3.41 3.61
(x103/uL)
Hb 14.8 12.5 - - - 11.7 11.3 11.6
(mg/dl)
PLT 151 143 - - - 587 509 448
(x103/uL)
Table 1. Evolution of the abnormal blood parameters

COURSE AND TREATMENT: at admission, on was still high (150/90mmHg) so he received 5 mg of

21.04.2017, the patient was agitated and suffering alcohol
withdrawal with diaphoresis, tachycardia and tremor of
extremities. He received at 8:30 pm intravenously 500 ml
of 5% Glucose with 400 mg of vitamin B1 and 100 mg of
vitamin B6 (both in injection form, administered in
perfusion), 1 mg of lorazepam, 300 mg of Carbamazepine
and 50 mg of Metoprolol. At 2:45 am his blood pressure
enalapril and 1 mg of lorazepam.
On 22.04 at 08:30 am his physical state was good, he was
cooperating and slept during the night, with normal blood
pressure and 94bpm pulse. He received 500 ml of 5% iv
glucose and 500 ml Ringer solution with 400 mg of
Thiamine and 100 mg of vitamin B6, 3 mg of lorazepam
(1-1-1) and 300 mg of Carbamazepine at 8 pm. Metoprolol

40

was not administered.
On 23.04 he became agitated and he was under contention
(both arms and legs) for 2 hours (2:30-4:30 pm), with
control of the state and vital signs at every 15 minutes. He
also received 10 mg diazepam im. At 9:50 pm he became
agitated and hetero-aggressive with the medical
personnel, so he was administered 50 mg of Metoprolol
(pulse 134 bpm), 300 mg of Carbamazepine and 10 mg of
Diazepam. His state didn't show any improvement, he was
hetero-aggressive still at 10 pm so contention was started
and maintained for 2 hours. At 4 am on 24.04 he became
agitated and hetero-aggressive again, needing contention
for 2 hours and another im injection of 10 mg of
Diazepam. At 8:30 am on 24.04 he tried to tear his iv
catheter so he needed contention again for 1 hour in order
to administer the iv fluids.
On 24.04.2017 at 9 am the patient arrived on the ward.
Blood parameters were tested. The patient was
cooperative, partially oriented in time and space, auto and
allopsychic oriented. He wasn't delirious, no signs of
alcohol withdrawal. He was requesting beer and a
cigarette. He was sent for neurological and internal
medicine examination, as the blood parameters were
abnormal (very high creatine kinase level). He was
physically stable, not presenting any fever, no meningeal
signs present. He was administered 2500 ml of iv fluids
(500 ml Glucose 5%, 1000 ml Ringer solution and 1000
ml saline), same dose of vitamin B1 and B6 with the iv
fluids, 1 mg of lorazepam (adding 1 mg in case of
agitation), 300 mg of carbamazepine morning and
evening (1-0-1), 1000 mg of silymarin and 250/50 mg
levodopa/carbidopa combination, divided in four quarters
throughout the day. Contention and intra-muscular
injections were forbidden. The next day the patient was
cooperating, no agitation nor hetero-aggressive outbursts
during the night, but presenting hematuria and glucose in
urine. He was aware, afebrile (36.6 degrees temperature),
normal blood pressure and no neurological nor alcohol
withdrawal symptoms. Internal medicine and
neurological consult indicated following the patient state
and hydration. He stayed on the same treatment until
06.05.2017, with very good evolution, blood parameters
becoming normal as time passed. The combination of
levodopa/carbidopa was withdrawn at neurologist's
indication and as the patient started drinking liquids orally,
intravenous fluids were also withdrawn. He was
discharged with carbamazepin 300 mg (1-0-1), lorazepam
1 mg (1-0-1), silymarin 1000 mg (1-0-0) and vitamin
B1+B6 in oral form. Even if the evolution had a favorable
course, the patient wasn't fully compliant to treatment and
he continued alcohol consumption. He had 2 more
admissions for alcohol withdrawal, the last one being in
December 2017. We mention that during the last 2
admissions his physical state was stable and his blood
parameters including creatine kinase were normal, with
the exception of liver enzymes and GGT.
Romanian Journal of Psychiatry, vol. XX, No.1, 2018
DISCUSSION: This case was very intriguing because of
the elevated creatine kinase in spite of the lack of
neuroleptic treatment. We took into consideration all the
differential diagnoses that could cause such a high
elevation of this enzyme level (myocardial infarction,
myocarditis, malignant hyperthermia, neuromuscular
diseases, auto-immune myopathies, periodic paralyses,
muscular traumas and high physical effort) but the patient
didn't present any signs or symptoms that would suggest
any other diagnosis. The abnormal blood parameters
suggested liver toxicity due to alcoholism and renal
disturbances due to myoglobinuria. His white blood cells
were elevated but the patient was afebrile and the internal
medicine consult didn't recommend antibiotic treatment,
attributing this abnormality to dehydration. He had mild
anemia and his potassium levels were low for a couple of
days. All the parameters came back to normal up to the
discharge date, except for hemoglobin, which was
maintained slightly under the normal limits (11.6 mg/dl).
The patient was not receiving neuroleptic treatment prior
to admission, and didn't receive any antipsychotic agent
during hospitalization, fact that eliminates the possibility
of neuroleptic malignant syndrome. The only possible
cause that could explain the extremely high creatine
kinase would be the agitation that necessitated repeated
contention for a long time, the patient also suffering from
spastic tetraplegia with muscle contraction that could lead
to rhabdomyolysis.
CONCLUSION: We consider this case very interesting
because having such an elevated CK level in the absence
of neuroleptic treatment is not very frequent in the
psychiatry units. The particularity of the case was the lack
of a particular cause that would lead to very high CK and
the good evolution, as the patient didn't progress to renal
failure and his CK level returned to normal in 15 days
time.
REFFERENCES:
1.High Serum Creatinine Kinase Level: Possible Risk Factor for
Neuroleptic Malignant Syndrome- Hermesh, Haggai MD*; Manor, Iris
MD*; Shiloh, Roni MD*; Aizenberg, Dov MD*; Benjamini, Yoav PhD†;
Munitz, Hanan MB, BS*; Weizman, Abraham MD*, Journal of Clinical
Psychopharmacology: June 2002 - Volume 22 - Issue 3 - p 252-256
2.Creatine kinase elevations in marathon runners: relationship to training
and competition- A. J. Siegel, L. M. Silverman, and R. E. Lopez, Yale J
Biol Med. 1980 Jul-Aug; 53(4): 275–279.
3.Paola Brancaccio, Nicola Maffulli, Francesco Mario Limongelli;
Creatine kinase monitoring in sport medicine, British Medical Bulletin,
Volume 81-82, Issue 1, 1 January 2007, Pages 209–230,
https://doi.org/10.1093/bmb/ldm014
4.Skogseid, I.M., Nordby, H.K., Urdal, P. et al. Acta neurochir (1992)
115: 106. https://doi.org/10.1007/BF01406367
5.Malignant Hyperthermia Testing in Patients with Persistently
Increased Serum Creatine Kinase Levels, Weglinski, Margaret R. MD;
Wedel, Denise J. MD; Engel, Andrew G. MD, Anesthesia & Analgesia:
May 1997 - Volume 84 - Issue 5 - p 1038-1041
***
41
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paragraphs, labeled Background, Objective(s), Method(s), Result(s), and Conclusion(s).
b) Keywords maximum of 6 keywords (minimum of 3), according to Index medicus. Keywords should not
repeat the title of the manuscript.
4. Fourth page and next:
• Original papers organized in:
a) Introduction (no more than 25% of the text), material and methods, results, comments or discussions and
43
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:
Vraşti R, Matei VMI. The crisis centre in Romania. Eur J Psychiat 2002; 29:305-311.
Reynolds CF, Frank E, Perel JM et al. Treatment of consecutive episodes of major depression in the elderly. Am J
Psychiat 1994; 151(12):1740-3.
- Reference to a book:
Vrasti R. The crisis centre in psychiatry. Toronto, London: Academic Press, 1993, 26-52.
- Reference to a chapter in an edited book:
Schuckit MA. Alcohol-Related Disorders. In: Sadock BJ, Sadock VA, Ruiz P (eds). Comprehensive Textbook of
Psychiatry. Philadelphia: Lippincott Williams and Wilkins, 2009, 1268-1287.
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.

44
 Romanian Journal of Psychiatry, vol. XX, No.1, 2018

Address to send the manuscripts is:

REVISTA ROMÂNĂ DE PSIHIATRIE

ASOCIAŢIA ROMÂNĂ DE PSIHIATRIE ŞI PSIHOTERAPIE
Prof. Dr. Dan PRELIPCEANU
Clinical Hospital of Psychiatry “Prof. Dr. Alexandru Obregia”
Şos. Berceni 10, sector 4, 041914 Bucureşti
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

45
 ROMANIAN JOURNAL
OF PSYCHIATRY
CONTENTS

ABSTRACTS - THE XITH NATIONAL CONFERENCE OF BIOLOGICAL EDITOR-IN-CHIEF: Dan PRELIPCEANU

PSYCHIATRY AND PSYCHOPHARMACOLOGY, CRAIOVA, CO-EDITORS: Dragoş MARINESCU
APRIL 18-21, 2018 1 Aurel NIREŞTEAN

ASSOCIATE EDITORS:
REVIEW ARTICLES Doina COZMAN
Liana DEHELEAN
& A Review of Performance-based Executive Function Tasks in Adults with Marieta GABOŞ GRECU
Maria LADEA
Autism and Normal Intelligence 19 Cristinel ŞTEFĂNESCU
Ilinca Mihailescu, Alina A. Frunză, Emanuela L. Andrei, Florina Rad, Cătălina TUDOSE
Iuliana Dobrescu, Mirela Manea
Executive editor: Valentin MATEI
ORIGINAL ARTICLES
STEERING COMMITTEE:
Vasile CHIRIŢĂ (Honorary Member
& Romanian Psychiatric Residents' Opinion on Factors Which Influence of the Romanian Academy of
their Decision to Emigrate as Challenge for Reforms in Educational Medical Sciences, Iaşi)
and Medical System in Psychiatry 27 Michael DAVIDSON (Professor, Sackler
Adriana Mihai, Maria Silvia Trandafir, Lavinia Duică, Alex Mihai, School of Medicine Tel Aviv Univ.,
Mount Sinai School of Medicine,
Cosmin Lungu, Anca Livia Chiriță, Mihail Cristian Pîrlog New York)
Virgil ENĂTESCU (Member of the Romanian
& The Delay to the First Psychiatry Consult in Two Acute Inpatients Academy of Medical Sciences, Satu
Clinics in Romania 31 Mare)
Andreea R. Tirintica, Mihail C. Pîrlog, Dragoș O. Alexandru, Traian Ioana MICLUŢIA (UMF Cluj-Napoca)
Şerban IONESCU (Paris VIII Universiy, Trois-
Purnichi, Biatrice Mihălcuț, Mariana Dragomir, Laura Demijan, Aurel
Rivieres University, Quebec)
Nireștean, Adriana Mihai Mircea LĂZĂRESCU (Honorary Member of the
Romanian Academy
& Correlations Between the Affective Response and Aggressiveness Level of Medical Sciences, Timişoara)
at Patients with Psychotic Disorders 35 Juan E. MEZZICH (Professor of Psychiatry
Ionela N Cotos, Karol J Wild and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
CLINICAL CASE Sinai School of Medicine, New York
University)
& High Creatine Kinase in a Psychiatric Patient Without Antipsychotic Teodor T. POSTOLACHE, MD (Director,
Treatment 39 Mood and Anxiety Program,
Department of Psychiatry,
Ana-Anca Talașman, Alexandra Dolfi, Dan Prelipceanu University of Maryland School of
Medicine, Baltimore)
INSTRUCTIONS FOR AUTHORS 42 Sorin RIGA (senior researcher)
Dan RUJESCU (Head of Psychiatric Genomics
and Neurobiology
and of Division of Molecular and
Clinical Neurobiology,
Department of Psychiatry, Ludwig-
Romanian Journal of Psychiatry and Psychotherapy is recognized in Romanian National Council Maximilians-University, Munchen)
for Scientific Research in Higher Education, starting with January 2010, at B+ category Eliot SOREL (George Washington University,
Ż Washington DC)
Romanian Journal of Psychiatry and Psychotherapy is indexed in the international data base Index Maria GRIGOROIU-ŞERBĂNESCU
Copernicus – Journal Master List, starting with 2009. (senior researcher)
Ż Tudor UDRIŞTOIU (UMF Craiova)
Doctors subscribed to this journal receive 5 CME credits / year.
APR
Scientific articles published in the journal are credited with 80 CME credits / article.

www.romjpsychiat.ro