SPECIAL ARTICLES

CARDIOVASCULAR COMORBIDITY ASSOCIATED

WITH SCHIZOPHRENIA SPECTRUM DISORDERS
Veronica Ruanu, Roxana M Stoean, Mirela Manea, Bogdan E Patrichi,
Alina Frunz
Abstract :
Cardiovascular disease is a relatively common
comorbidity in patients with major psychiatric disorders.
The mortality rate of people with schizophrenia spectrum
disorders is described as excessive and premature. This is
due to the major psychiatric disorders, side effects of
psychotropic medication and improper lifestyle,
cardiovascular disease. Once developed the
cardiovascular diseases, patients with schizophrenia have
a reduced capacity to adhere to secondary prevention
programs, such as exercise and weight control through
proper diet.
Key words: cardiovascular disease, schizophrenia,
mortality, antipsychotics.
ACKNOWLEDGEMENT: This paper is supported by the
Sectorial Operational Programme Human Resources
Development (SOP HRD), financed from the European
Social Fund and Romanian Government under the
contract number POSDRU/159/1.5/S/137390/
Schizophrenia spectrum disorders (schizophrenia,
schizoaffective disorder, schizophreniform disorder, brief
psychotic disorder) is associated with numerous health
problems. Patients with these conditions are prone to
poverty, institutionalization and social isolation. They
have great difficulty in taking care of themselves, they
have inappropriate lifestyle because of sedentary,
inadequate nutrition, smoking and excessive consumption
of alcohol or other substances. There is also a socialprofessional degradation while the disease advances. Most
of the patients live in poverty, are socially isolated, are
unemployed or provides work below the level of their
parents, are married or divorced, have limited social
contacts outside the family, fail to achieve educational
goals. Often, there might occur a significant cognitive
impairment that persists during periods of remission of
psychotic symptoms and has a significant influence on the
ability of self-care and daily functioning.
The mortality rate of people with schizophrenia spectrum
disorders is described as excessive and premature (1). It is
considered that the death of these patients may occur with
10-25 years earlier, compared to the general population
(2). Men with schizophrenia or related disorders die with
20 years earlier, women with 15 years earlier, compared
with those without major psychiatric disorders. Suicide
can be a major cause for premature death, the remaining
causes of death being due to cardiovascular disorders,

diabetes, pulmonary disease as a result of excessive

smoking (approximately 70% of patients diagnosed with
psychotic disorders smoke) (3).
Patients with these conditions have an increased risk of
obesity (1.5-2 times higher), diabetes mellitus (2 times
higher), dyslipidemia (5 times higher), smoking (by 2-3
times more) compared to people who do not suffer from
these conditions (4).
Most antipsychotic drugs increase the risk of
comorbidities, leading to weight gain, elevated blood
sugar, cholestatic liver diseases (5).
It is thought that at least 10% of the people who
take antipsychotic drugs for a long time, shall develop
type 2 diabetes mellitus, two times more than the general
population. Also, it is thought that there is a common
genetic vulnerability, between psychosis and the risk of
diabetes.
An observational study conducted by Smith DJ, et al, on a
sample representing about a third of the population of
Scotland, tried to identify the most common
comorbidities associated with schizophrenia and related
psychotic disorders. The highest prevalence was obtained
for viral hepatitis, constipation or Parkinson's disease.
Other somatic diseases with high prevalence in patients
with disorders like schizophrenia compared with the
population undiagnosed with major psychiatric disorders
were diabetes, COPD, chronic pain, epilepsy, irritable

Psychiatry MD, PhD Student in Psychiatry, Bucharest Emergency Hospital

Psychiatry MD, Sf. Pantelimon Emergency Hospital, Bucharest
Senior Psychiatrist MD, PhD, Professor at Carol Davila University of Medicine and Pharmacy, Bucharest
Senior Psychiatrist MD, PhD at Carol Davila University of Medicine and Pharmacy, Bucharest
Resident in psychiatry, PhD Student in Psychiatry, Assistant Professor at Carol Davila University of Medicine and Pharmacy, Bucharest

Veronica Ruanu, Roxana M Stoean, Mirela Manea, Bogdan E Patrichi, Alina Frunz: Cardiovascular Comorbidity
Associated With Schizophrenia Spectrum Disorders
bowel syndrome. Surprisingly, cardiovascular disease,
high blood pressure, atrial fibrillation, coronary disease
and cancer had a lower prevalence in those with
schizophrenia compared with those without psychiatric
disorders, although many other studies see these as some
of the causes of premature death in this population (3).
According to the author, this may be due to the fact that
patients with major psychiatric disorders either do not see
the general practitioner of the cardiologist due to a low
acknowledgement of the cardiovascular symptoms or
their wrong interpretation, either because, despite the
frequent contacts with medical specialists, are less
investigated, monitored and they are not treated with the
same attention and consideration as the patients without
related psychotic disorders (3).
The authors of this study believe that the low
prevalence of high blood pressure is also due to the
hypotensive effect of psychotropic medication. Also
based on the adverse effects of antipsychotics may explain
the greater percentage of patients with constipation or
Parkinson's disease (anticholinergic effects, namely
neuroleptization effect, parkinsonian syndrome).
In the general population, QTc interval
prolongation is associated with increased cardiovascular
mortality with sudden death, especially in patients who
have had a history of diabetes mellitus and cardiovascular
diseases. In patients with psychiatric disorders, the QTc
interval prolongation is a consequence of antipsychotic
treatment, although schizophrenia is associated with
prolongation of the OTC interval even in the absence of
psychotropic medication. To this is added the presence of
metabolic syndrome and diabetes mellitus, frequently
encountered in patients with schizophrenia spectrum
disorders and further contribute to increased
cardiovascular mortality within this population. Alcohol
consumption, physical inactivity, poor adherence to
treatment plan required for those with cardiovascular
disease, the presence of other comorbidities determines an
additional negative influence. A comparative metaanalysis performed by AJ Mitchell and Lawrence D,
published in 2011, points out that after an acute
cardiovascular event, patients with a major psychiatric
disorder experience a 14% lower rate of invasive coronary
interventions (47% in those with schizophrenia) and have
an 11 percentage of mortality (6).
Once developed the cardiovascular disorder,
patients with schizophrenia have a reduced capacity to
adhere to secondary prevention programs, such as
exercise, weight control through proper diet, even weight
loss. A study published by Kurdyak P et al in 2012 had as
main objective to compare mortality upon 30 days of
hospital discharge after acute myocardial infarction
among patients with schizophrenia and those without. A
secondary objective has been to follow the process of
patient care (visits to the cardiologist and procedures
performed in the first 30 days after myocardial
percutaneous transluminal coronary or revascularization
intervention by coronary bypass). 71668 subjects were
included in the research, including 862 diagnosed with
schizophrenia. The study showed an increase in mortality
in patients with schizophrenia and myocardial infarction
within 30 days of discharge after the latter. With 56%
higher than for subjects with infarction, but undiagnosed
with schizophrenia. People with schizophrenia received
2

50% less adequate cardiac procedures or care compared

with people without this psychiatric disorder. Fewer than
1 in 4 patients with schizophrenia received interventional
cardiology procedure and only 12 of 100 had cardiac
check-ups within 30 days of discharge after an acute
myocardial infarction (7).
An observational study coordinated by the
Finnish Suvisaari J investigated the prevalence of
coronary heart disease and myocardial infarction in
people over 30 years, 71 diagnosed with psychotic
disorders in a sample of over 8,000 persons, considered
representative of the population of Finland, monitoring
EKG changes, mainly the prolongation of the OTc
interval, physical examination data and meaningful
information from patient observation charts. Only 71.2%
of people with psychotic disorders and coronary heart
disease reported having been diagnosed with heart disease
and were able to report if they followed cardiology
treatment, compared with only 88.5% of patients with
coronary artery disease. The main conclusion of this study
is that patients with schizophrenia are associated with
more severe forms of coronary artery disease, the presence
of Q infarction waves on the ECG and believes that
monitoring the signs and symptoms of coronary artery
disease should be more active in people with psychotic
disorders , in particular schizophrenia (8).
Two studies conducted by Curkendall SM and
McDermott S, respectively, indicated an incidence,
prevalence and an increased risk of congestive heart
failure but did not reveal a statistically significant increase
in the risk, prevalence or incidence of coronary disease in
patients with schizophrenia (9, 10).
CATIE study showed that after 10 years the risk of
developing coronary heart disease is increased in patients
with schizophrenia, compared with the general population
(11).
A study published by Jin et al in 2011 in
Schizophrenia Research, using the Framingham 10-year
coronary heart disease predictions (uses as predictors the
age of 30-74 years, diabetes, smoking, blood pressure,
total cholesterol and LDL cholesterol) suggests that
middle-aged patients with psychotic symptoms have the
Framingham 10 years prediction score of coronary heart
disease significantly increased, especially among those
with schizophrenia (12).
Type 2 diabetes is increased in prevalence in
individuals with major psychiatric disorders. This is
probably due both to antipsychotics that cause weight
gain, hyperglycaemia and dyslipidemia, as well as to the
improper lifestyle, lack of exercise, inadequate diet (13).
Type 2 diabetes increases the risk of cardiac disease for 2
to 4 times and it is considered to provide an equivalent risk
of a coronary event as the one induced by pre-existing
cerebrovascular disease. American Diabetes Association
recommended statins as the first-line therapy for the
treatment of hyperlipidaemia (inhibitors of 3-hydroxy-3methylglutaryl-coenzyme A (HMG-CoA) reductase), and
for those with diabetes and high blood pressure or kidney
disease, the same association recommends inhibitors of
the angiotensin converting enzyme and angiotensin
receptor antagonists. They are designed to improve
cardiovascular parameters and progression of diabetic
nephropathy where it exists. A study published in 2008 by
Kreyenbuhl J et al (14) showed that individuals who

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

frequently resort to mental health services have a
lower likelihood of being prescribed above mentioned
treatments to prevent cardiovascular risk in patients with
diabetes and dyslipidemia or high blood pressure or
diabetes and diabetic nephropathy (14).
Another study published this year, sought to
identify the most common causes of sudden death in
patients with schizophrenia, based on autopsy reports.
From a sample of 7189 patients with schizophrenia,
admitted to a psychiatric hospital for 25 years, 57 have
died suddenly. The cause of death was myocardial
infarction 52.9%, followed by respiratory diseases
(pneumonia 11.8%, obstructed airways 7.8%),
myocarditis 5.9%, in other cases the sudden death was
due, in equal measure of about 2 %, to pulmonary
embolism, dilated cardiomyopathy, haemorrhagic
cerebral accidents, haemopericardium and brain tumours
(15).
Antipsychotic medication causes a number of
cardiovascular complications: orthostatic hypotension,
high blood pressure, arrhythmia, myocarditis. Orthostatic
hypotension is due to blocking of adrenergic 1 or
anticholinergic effects of antipsychotic medication. A
persistent hypotensive effect was associated with
significant side effects, such as stroke and myocardial
infarction, in severe cases (16).
Torsades de pointes, a polymorphic ventricular
tachycardia associated with QTc interval prolongation
(17). Although often resolves itself, torsade de pointes
may cause sustained ventricular fibrillation and sudden
death (16). Several atypical antipsychotics can cause QT
interval prolongation. Myocarditis, inflammation of the
heart muscle is a rare side effect, caused by clozapine (18).
Patients with psychiatric disorders from the
schizophrenia spectrum can associate a number of
cardiovascular diseases during evolution. These are due to
the major psychiatric disorders, side effects of
psychotropic medication and inadequate living style.
Perhaps an essential feature of these patients is the neglect
of health in general. Compared to the general population,
may provide much less information about related
comorbidities, specific treatments recommended and are
certainly much less adherent to therapeutic indications,
especially those involving lifestyle changes through
proper nutrition, exercise, giving up unhealthy habits,
such as smoking or excessive alcohol consumption.
Although, paradoxically, they have some more contact
with health systems than the general population, quality of
care received is lower. This may be due to the fact that
experts consider a sign of "mental instability" frequent
contacts of patients with psychiatric services, which could
mean a weak capacity of understanding and compliance
with therapeutic recommendations. However, this only
renders vulnerable, once more, this special category of
patients with significantly impaired quality of life.
REFERENCES
1. Mayer JM, Nasrallah HA. Medical illness and
schizophrenia. Second edition. England: London, 2009,
17. ISBN 978-1-58562-346-4
2. Hennekens CH. Schizophrenia and increased risks of

cardiovascular disease. American Heart Journal 2005:

115-121.
3. Smith DJ. Schizophrenia is associated with excess
multiple physical health comorbidities but low levels of
recorded cardiovascular disease in primary care: crosssectional study. BMJ Open 2013: 3.
4. Lambert T, Newcomer JW. Are the cardiometabolic
complications of schizophrenia still neglected? Barriers to
care. Medical Journal 2009;190(4 Suppl): S39-42.
5. Levenson JL. Textbook of psychosomatic medicine.
Psychiatric care of the medically ill. Second edition. The
American Psychiatric Publishing, 2011. ISBN 978-158562-379-2
6. Mitchell AJ. Revascularisation and mortality rates
following acute coronary syndromes in people with severe
mental illness: comparative meta-analysis. The British
Journal of Psychiatry 2011;198: 434-441.
7. Kurdyak P. High mortality and low access to care
following incident acute myocardial infarction in
individuals with schizophrenia. Schizophrenia Research
2012;142: 52-57.
8. Suvisaari J. Coronary heart disease and cardiac
conduction abnormalities in patients in persons with
psychotic disorder in a general population. Psychiatry
Research 2010;175: 126-132.
9. Curkendall SM. Cardiovascular disease in patients with
schizophrenia in Saskatchewan, Canada. Journal of
Clinical Psychiatry 2004;65: 715-720.
10. McDermott S. Heart disease schizophrenia and
affective psychoses: epidemiology of risk in primary care.
Community Mental Health Journal 2005;41: 747-745.
11. Goff DC et al. A compare study of ten-year cardiac risk
estimates in schizophrenia patients from the Catie study
and matched controls. Schizophrenia Research
2005;80(1): 45-53.
12. Jin H et al. Increased Framingham 10-year risk of
coronary heart disease in middle-age and older patients
with psychotic symptoms. Schizophrenia Research
2011;125: 295-299.
13. Newcomer JV. Second-generation (atypical)
antipsychotics and metabolic effects: a comprehensive
literature review. CNS Drugs 2005;19(supp 1): 1-93.
14. Kreyenbuhl J. Use of medications to reduce
cardiovascular risk among individuals with psychotic
disorders and type 2 diabetes. Schizophrenia Research
2008; 256-265.
15. Ifteni P. Sudden unexpected death in schizophrenia:
Autopsy findings in psychiatric inpatients. Schizophrenia
Research 2014;155: 72-76.
16. Khasawneh F. Minimizing cardiovascular adverse
effects of atypical antipsychotic drugs in patient with
schizophrenia. Cardiology Research and Practice 2014.
doi:10.1155/2014/273060
17. Justo D. Torsade de pointes induced by psychotropic
drugs and the prevalence of its risk factors. Acta Psychiatr
Scand 2005;111(3): 171-6.
18. Haas SJ. Clozapine-associated myocarditis: a review
of 116 cases of suspected myocarditis associated with the
use of clozapine in Australia during 1993-2003. Drug
Safety 2007: 47-57.
***

SPECIAL ARTICLES

ADULT ADHD A NEW ENTITY IN PSYCHIATRY

(DSM V)
Laura Aelenei 1
Abstract:
Subject of a series of controversies in the recent literature,
the ADHD diagnosis became with the new classification in
DSM V a new entity in adult psychiatry.
ADHD symptoms in adults, attention deficit, impulsivity
and hiperkinesia may interfere with functionning, the
disorder being associated with poor socioeconomic
outcome, impairment in different areas and high rates of
psychiatric comorbidity.
There has been a growing interest in studying the course of
the disease in the adult life. Research in the recent
literature followed several ideas. Some studies evaluate
the association with other diagnoses such as anxiety,
depression, cyclothymia, dysthymia, substance use
disorders, etc. An interesting perspective is a longitudinal
one, some researchers seeing simptoms that persist from
childhood to adulthood, capable of interacting with the
developement of the individual's personality, leading to
personality disorders. There have been made associations
with temperament and character dimensions.
To conclude, we can say that studying the ADHD
pathology in the adult age may lead to a different
perspective on some of the disfunctionalities of some of our
patients that can improve the quality of their life.
Key words: Adult ADHD, personality disorder,
hiperactivity, impulsivity, attention deficit.

Attention-deficit/hyperactivity disorder
(ADHD) is characterized by a persistent pattern of
inattentive, hyperactive, and impulsive behavior that
begins early in childhood, often persists throughout
development, and interferes with adaptive functioning
(1).
Traditionally considered a disorder belonging to
the child and adolescent psychiatry, ADHD is now a
condition that gathers several simptoms that are
recognized also in adult psychopathology. After several
years of debating whether or not it should be considered
this diagnosis in adult psychiatry, from the DSM V
perspective there is a well established diagnosis of adult
ADHD.
Historically, the adult ADHD diagnosis has
been the subject of many controversies, starting from the
mid-1970s, when Wender and colleagues at the University
of Utah published initial findings on minimal brain
dysfunction in adults. Studies of adults diagnosed as
hyperactive in childhood and clinical descriptions of
childhood hyperactivity persisting in adults with other
psychiatric disorders where the elements that led Wender
to consider the possible persistence of ADHD into

adulthood .
Today, it is estimated that 5%8% of schoolaged children and 4% of adults in the United States suffer
from some form of attention deficit disorder, DSM V
suggesting 5% in children and 2,5% in adults. In terms of
gender it is considered the following proportion: B/F=2/1
(1,6/1 adults) (1).
In DSM V the perspective on ADHD diagnosis
has been changed, in the direction of facilitating the
diagnosis: the age of the symptoms' onset is 12 instead of
7, the number of symptoms necessary for diagnosis is 5 in
adults.
As we know, nowadays a corect examination
and diagnosis is a clinical examination sustained by a
standardised evaluation. To explore the adult ADHD
pathology, based on the DSM-IV criteria, clinicians use
the Diagnostic Interview for ADHD in Adults (DIVA),
scale developed by J.J.S. Kooij and M.H. Francken (2, 3).
It follows the earlier Semi-Structured Interview for
ADHD in adults. The scale evaluates the symptoms
present (18 criteria ) in both chilhood and adulthood and
gives examples from everyday life, that makes the
evaluation easy to perform. The information is taken from

1
Psychiatry MD, PhD Student in Psychiatry, Bucharest, Romania
Received November 12, 2014, Revised December 15, 2014, Accepted January 05, 2015

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

the patient and it can be sustained by another family
member. Other instruments used are Wender Utah Rating
Scale, Conners Rating Scale (2, 3).
There is considerable interest in development of
nonclinical, laboratory tests for adult ADHD, a reason
being the fact that these methods are more objective than
clinical interviews and clinical diagnostic criteria. There
are different researchers that used tests of executive
functioning and working memory, laboratory tests of
attention, quantitative electroencephalography,
neuroimaging methods using proton magnetic resonance
spectroscopy (4, 5, 6, 7).
The research shown neurocognitive and
biological differences between persons with and without
ADHD.The majority of studies are limited though to small
numbers of subjects. Another issue is the financial one,
because laboratory assessments involve significantly
more expense than rating scales and clinical interviews,
and they have no proven advantage over clinical diagnosis
of ADHD (8).
Given its history, the disorder has been better
studied in children. The latest data show that the
persistance of ADHD simptoms in the areas of attention
deficit, impulsivity and hiperkinesia in adult life may
interfere with functionning. In adults hiperactivity,
manifested by reslessness, is less proeminant than in
children. Impulsivity leads to hasty actions, potentialy
harmful, interrupting others, bad decision making.
Inatention leads to bad concentration, disorganised work.
Even if in most of the cases the intensity of the
simptomatology is weaker than in children, it was shown
that in time it is frequently associated with clinical and
psychological impairments. ADHD has been associated
with poor socioeconomic outcome, functional
impairments and high rates of psychiatric comorbidity, or
some unpleasant events such as car accidents. For some
adults, simptoms can be unrecognised and explained by
other diagnoses such as anxiety, depression, cyclothymia,
dysthymia, personality disorders, bipolar disorders,
substance use disorders (9, 10, 11, 12).
Given the increasing evidence of the impact of
this disease on functionality, there has been a growing
interest in studying the course of the disease in the adult
life. There have been several lines of research in the recent
literature.
Some have examined the association between
ADHD severity and the lifetime prevalence of other
psihiatric conditions in adults with ADHD, such as
depressive episodes, anxiety disorders, substance use
disorders (9, 10, 11).
Another issue approached was the differential
diagnosis of ADHD and he possibility of different
interpretation of symptoms. An example is the differential
diagnosis with Bipolar Disorder. There are some elements
to consider if we are thinking of an affective disorder. The
clinical picture in mania includes euphoria, mood
changes, irritability, distractibility, inattentiveness,
polipragmasia, overactivity, increased energy, insomnia.
Some symptoms are similar to those in ADHD. But, to a
closer look, in a longitudinal analysis, there are some
differences. The course of bipolar disorder is an episodic
one, with an intensity variation of symptoms in time,
meanwhile, in ADHD the symptoms are somehow
constant (10). In depressive disorders the depressive

mood can be sometimes accompanied by restlessness,

incapacity to relax, even agitation, irritability, but the
accent of the patient`s complains is usually on he ideas of
incapacity, uselessness.
Let us look closer to the area of personality
disorders. Unlike affective disorders, that have an episodic
pattern, personality disorders have symptoms that are
relatively constant in time, somehow similar to ADHD
symptoms.
A personality disorder is an enduring pattern of
inner experience and behavior that deviates markedly
from the expectations of the individual's culture, is
pervasive and inflexible, has an onset in adolescence or
early adulthood, is stable over time, and leads to distress
and impairment (DSM V) (1). In DSM V the classic
approach of personality disorders remained the same, but
it has also been elaborated an alternative model for this
pathology. The ten specific personality disorders are
grouped as we know in three clusters (cluster A: paranoid,
schizoid, schizotypal; cluster B: antisocial, borderline,
histrionic, narcissistic; cluster C: avoidant, dependent,
obsessive-compulsive) (1). Latest data suggest that 1020% of the general population has a personality disorder.
The alternative model is a dimensional one. Personality
disorders are characterized by impairments in personality
functioning (identity, self-direction, empathy, intimacy)
and pathological personality traits (Negative affectivity,
Detachment, Antagonism, Disinhibition, Psychoticism)
(1). This approach is somehow similar to the spectrum
approach used in other disorders, having the aim to better
evaluate the individual in a population in which traits are
continuously distributed (1).
If we are referring to personality disorders in
cluster B, antisocial and borderline PD, often associated
with substance use pathology (alcohol, opioids,
amphetamines, cocaine, etc) and pay attention to the
sequence of symptoms and their evolution, there are a few
things to be observed. Longitudinal studies show that
symptoms that lead to a diagnosis of ADHD are visible at
the beginning. In time they may lead to the development of
antisocial behavior, evolution thought to be mediated by
environmental influences (12, 13).
Another direction in recent literature has been
the interest in the characterization of patients with early
and late onset of ADHD impairment in terms of
neuropsychological and personality characteristics. There
were some researchers that describe correlations between
the temperament and its dimensions the way it was
classically described by Cloniger and symptoms of
ADHD. Temperament describes an individual's profile of
biological response patterns to external stimuli, which is
reflected in individual differences in emotional responses
to the environment. The independent dimensions are:
novelty seeking (NS), harm avoidance (HA), reward
dependence (RD), and persistence (PS) (14, 15, 16, 17).
A very interesting aproach of the idea that what
happens during childhood has an impact on future
pathology is described by Henrik Anckarsarter in his study
. His hypothesis is that ADHD and autism spectrum
disorders are associated with specific temperament
configurations and an increased risk of personality
disorders and deficits in character maturation (18).
In his study he evaluated adults with specific
instruments like TCI, SCID-II for personality disorders
5

Laura Aelenei: Adult Adhd A New Entity In Psychiatry (dsm V)

disorders and scales for other neuropsychiatric disorders

(18). Keeping in mind the Cloninger's biopsychosocial
theory of personality (based on the assumption that
personality involves four temperament dimensions and
three character dimensions), he assessed the individuals'
abilities such as attention, impulse control, adaptive
decision-making strategies, adequate perception, control
of voice, posture, mimicry, interpersonal skills,
mentalizing (18). Their variation may influence in his
opinion personality development to a greater extent than
recognized in current personality theory (18). His ideas
are that certain childhood temperament profiles may
impair healthy character development, producing
personality disorders in adulthood (18). Patients with
ADHD were shown to have high novelty seeking and high
harm avoidance. Cluster B personality disorders were
more common in subjects with ADHD, while cluster A and
C disorders were more common in those with autism
spectrum disorders. The overlap between DSM-IV
personality disorder categories was found to be high (18).
Personality disorders were found to be common in followup studies of subjects with neuropsychiatric disorders.
The conclusion was that a patient with a childhood-onset
neuropsychiatric disorder, particularly if previously
undiagnosed, might well be diagnosed as having a
"primary" personality disorder when assessed in adult
age (18).
If we are to consider the therapeutic area, we
find elements to sustain the importance of the ADHD
diagnosis. Stimulant medication (atomoxetine,
methylphenidate) has proven its efficacy in treating
ADHD symptoms in child for years. Medication has been
used with success in adults but the experience is more
limited. There is now an interest in studying the efficacy of
stimulant medication in reducing the evolution of
simptoms in adult life (19). There are however several
controversies regarding the risks and benefits of the
therapy. One of the concerns is the potential for addiction
of the stimulant medication.
As a conclusion, we can say that exploring the
area of ADHD pathology, especially the persistance of
symptoms in the adult life would lead to an important
improvement of the quality of life of some of our patients.
Some of the simptoms misdiagnosed at first can benefit of
specific treatment that can influence the evolution of the
disease and prevent complications.
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American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders. 5 ed. Washington, DC: American
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Diagnoses Valid? Am J Psychiatry 2006;163: 1720-1729.

doi:10.1176/appi.ajp.163.10.1720.
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7. Biederman J, Petty C, Fried R et al. Impact of Psychometrically
Defined Deficits of Executive Functioning in Adults With Attention
Deficit Hyperactivity Disorder. Am J Psychiatry 2006;163: 1730-1738.
doi:10.1176/appi.ajp.163.10.1730
8. Hinnenthal J, Perwien A, Sterling K. A Comparison of Service Use and
Costs Among Adults With ADHD and Adults With Other Chronic
Diseases. Psychiatric Services 2005. doi: 10.1176/appi.ps.56.12.1593
9. Biederman J, Petty C, Wilens T et al. Familial Risk Analyses of
Attention Deficit Hyperactivity Disorder and Substance Use Disorders.
Am J Psychiatry 2008;165: 107-115. doi:10.1176/appi.ajp.2007.
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10. Faraone S, Biederman J, Wozniak J. Examining the Comorbidity
Between Attention Deficit Hyperactivity Disorder and Bipolar I
Disorder: A Meta-Analysis of Family Genetic Studies. Am J Psychiatry
2012;169: 1256-1266. doi:10.1176/appi.ajp.2012.12010087
11. Watts V. Addressing Comorbid ADHD, Substance Abuse Disorder in
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12. Biederman J, Petty C, Monuteaux M et al. Adult Psychiatric
Outcomes of Girls With Attention Deficit Hyperactivity Disorder: 11Year Follow-Up in a Longitudinal Case-Control Study. Am J Psychiatry
2010;167: 409-417. doi:10.1176/appi.ajp.2009.09050736
13. McGough J, Barkley R. Diagnostic Controversies in Adult Attention
Deficit Hyperactivity Disorder. Am J Psychiatry 2004;161: 1948-1956.
doi: 10.1176/appi.ajp. 161.11.1948
14. Barkley RA, Murphy KR. Deficient emotional self-regulation in
adults with attention-deficit/hyperactivity disorders (ADHD): the
relative contributions of emotional impulsiveness and ADHD symptoms
to adaptive impairments in major life activities. J ADHD Relat Disord
2010; 1: 5-28.
15. Barkley RA. Deficient emotional self-regulation: a core component
of attention-deficit/hyperactivity disorder. J ADHD Relat Disord
2010;1: 5-37.
16. Khushmand R, Trampush J, Rindskopf D et al. Association Between
Variation in Neuropsychological Development and Trajectory of ADHD
Severity in Early Childhood. Am J Psychiatry 2013;170: 1205-1211.
doi:10.1176/appi.ajp.2012.12101360
17. Surman C, Biederman J, Spencer T et al. Deficient Emotional SelfRegulation and Adult Attention Deficit Hyperactivity Disorder: A
Family Risk Analysis. Am J Psychiatry 2011;168: 617-623.
doi:10.1176/appi.ajp.2010. 10081172
18. Anckarster H, Stahlberg O, Larson T et al. The Impact of ADHD and
Autism Spectrum Disorders on Temperament, Character, and
Personality Development. FOCUS Spring 2010;8(2): 269-275.
19. Reimherr FW, Marchant BK, Strong RE et al. Emotional
dysregulation in adult ADHD and response to atomoxetine. Biol
Psychiatry 2005;58: 125-131.

***

REVIEW ARTICLES

DIAGNOSING PERSONALITY DISORDERS:

A MODERN VIEW
Istvn Zs Szsz1, Adrian I Horvath2, Tudor Niretean3, Anna M Tth4
Abstract:
The alternative DSM-5 model for personality disorders
(PD) evaluates the level of personality functioning on a
continuum and considers that the disturbances in self and
interpersonal functioning constitute the core of
personality psychopathology. Although the above
mentioned model integrates the experiences of the last
decades in an elegant manner, it cannot be considered a
model that fully reflects the expected holistic approach of
PD. In this article we will try to analyze PD from the
perspective of the alternative DSM-5 model, pointing out
the importance of moral conscience, defense mechanisms
and life events when assessing personality and to propose
an algorithm to diagnose PD in a manner that might help
clinicians to establish a more individualized treatment
strategy.
Key words: Personality disorders, moral conscience,
traumatizing life events, defense mechanisms.

INTRODUCTION
The past decades brought a lot of theories on the
structure of personality organization, on personality
disorders and we strived to find strategies and algorithms
to diagnose and treat these conditions. The categorical
approach seemed to bring too less information about the
person and leaves no room for individualized treatment
strategies. The differences between two persons diagnosed
with borderline personality disorders can be so significant
that it is impossible to find a common guideline to even try
treating them. Of course this led researchers to introduce
the dimensional approach which brings a lot of
information about the trait profile of a person and
conserves the continuum between normality and
pathology.
But what is a personality disorder? We probably
agree on the fact that it is a condition when nature and
nurture form a personality that can't cope with the
problems of everyday life and this state finally leads to
suffering. The above statement is adopted by different
models in different ways. Phenotypic trait personality
models, like the five factor model, are extremely useful,
but as we know there are a lot of overlaps between different

domains. Developmental trait personality models take

into account both the underlying biological dispositions
to observable behaviors and individual differences in
responses to experience during personality development
(1). A developmental personality model is Cloninger's
seven factor model, which needs to be mentioned because
the model stated 20 years before the introduction of DSM5, that a personality disorder is a deficiency of self and
interpersonal functioning, namely low scores on Selfdirectedness and Cooperativeness(2). So the alternative
DSM-5 model of PD could be considered a good effort to
combine the above mentioned dimensional models. This
model defines PD as moderate or greater impairment in
personality functioning and the presence of at least one
pathological personality trait which can be assessed with
The Personality Inventory for DSM-5(PID-5) (3).
When diagnosing PD the clinician has to be aware that
after the diagnosing procedure he has to establish a
therapeutic plan which can consist of psychotherapy
alone or in combination with the psychopharmacological
treatment. First we will present our concerns about the
alternative DSM-5 model then we will describe the utility
of mapping traumatizing life events and defense
mechanisms.

11

MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures. Correspondence: szaszisti2009@yahoo.com
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.
3
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.
4
Medical Student, University of Medicine and Pharmacy, Targu Mures.
Received September 05, 2014, Revised October 31, 2014, Accepted November 28, 2014
2

Istvn Zs Szsz, Adrian I Horvath, Tudor Niretean, Anna M Tth: Diagnosing Personality Disorders:A Modern View

Our first concern about this model is that it tries to obtain

informations about the person who is egosintonic with his
functioning and traits. For example a person with PD
rarely knows or admits that he is seen as irresponsible by
others with think that questions shut be much more
indirect in some cases. Of course there is an informant
form for PID-5, but unfortunately we hardly get them
filled out in clinical settings.
One of our previous studies showed that from a
psychopharmacological point of view traits which are
allocated to self-esteem and individual superego seem to
be difficult to integrate, namely manipulativeness,
d e c e i t f u l n e s s , g r a n d i o s i t y, c a l l o u s n e s s a n d
irresponsibility.
Except grandiosity, which can be considered a
pathological defense mechanism, these traits belong to the
moral consciousness and therefore should be integrated as
part of the interpersonal functioning or separately because
it can be a target for psychotherapeutic interventions. If
assessed separately moral consciousness should contain
another facet called moral torture. This facet could be
describes as follows: directly and deliberately disparage,
slander, calumniate or defame someone to satisfy ones
sadic pleasures (4).
We think that in a holistic approach it is extremely
important to obtain informations about traumatizing
events in early life and defense mechanisms.
Traumatizing events in early life
It is well known that our character's maturity
depends on environmental factors that occur during
childhood and this is also the period of acquiring mature
defense mechanisms. Figure 1. explains these views.

Figure 1. The development of character and defense

mechanisms. At the age of 3 character begins to develop and
reaches a level that can control temperament at age of 18.
Around age 35 character reaches maturity and starts its
physiological decline around the age of 60. Any traumatizing life
event can slow down or stop character development which leads
to an immature character and implicitly to a PD. However, a
mature character is not an insurance for a life: cranio-cerebral
traumatisms and substance abuse can also affect character and
accelerate the physiological decline resulting in an organic PD.
The development of mature defense mechanisms has a similar
path

When mapping the traumatizing events in early

life we could use an adopted version of DSM-IV Axis IV
(5) (Table 1.)
8

Problems with
primary support
group

Death of a family
member
Health problems in
family
Disruption of
family by
separation, divorce,
or estrangement
Removal from the
home

Problems
related to the
social
environment/E
ducation
Inadequate
social support
Discrimination
Discord with
teachers
or classmates

Housing/
Economic
problems

Inadequate
housing
Unsafe
neighborhood
Inadequate
finances

Inadequate
school
environment

Remarriage of
parent
Sexual or physical
abuse
Neglect of child
Table 1. Proposed classification of traumatizing life events .

Defense mechanisms
In the pathology of personality it is important to
map the defense mechanisms because it can have a crucial
influence on the treatment strategy we want to adopt. If the
character develops and reaches maturity the person can
adopt mature defense mechanisms like humor, altruism or
sublimation. Unfortunately in PD the character does not
reach maturity which automatically involves pathological
defense mechanisms. Cluster A PDs use projection and
fantasy, Cluster B PDs can use acting out, denial,
somatization and Cluster C PDs use undoing and
idealization. A primitive defense mechanism classified as
pathological defense mechanism is splitting which is
typical for borderline PD. To map these defense
mechanisms we can use Vaillant's categorization of
defense mechanisms which includes 4 levels :
pathological, immature, neurotic and mature defense
mechanisms (6). Mature defense mechanisms are not
shown in the table, they include patience, humility,
acceptance, anticipation and a lot more.
Pathological
Delusional
projection
Conversion
Denial
Distortion
Splitting
Extreme
projection
Superiority
complex
Inferiority
complex

Immature
Acting out

Neurotic
Displacement

Fantasy
Wishful thinking
Idealization
Passive aggression
Projection

Dissociation
Hypochondriasis
Intellectualization
Isolation
Rationalization

Projective
identification
Somatization

Reaction formation
Regression

Repression
Undoing
Withdrawal
Upward and downward
social comparisons
Table 2. Proposed classification of traumatizing life events

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

Our proposed algorithm to diagnose PDs starts with the
clinical diagnosis that includes also the mapping of
traumatizing life events, defense mechanisms and facets

of moral conscience followed by the PID-5 without

assessing the domain of Antagonism as shown in figure
2.

Figure 2. Proposed algorithm to diagnose personality disorders. TCI-Temperament and character inventory; SD-self-direction; COCooperativeness; PF-personality functioning; SCID-II- The Structured Clinical Interview for DSM-IV Axis II Personality Disorders

REFERENCES
1.Sadock B.J, Sadock V.A, Ruiz P. Kaplan & Sadock's Comprehensive
Textbook of Psychiatry, 9th Edition. New York: Lippincott Williams and
Wilkins, 2009.
2.Cloninger C.R. The temperament and character inventory (TCI): A
guide to its development and use. St. Louis, MO: Center for
Psychobiology of Personality: Washington University, 1994.
3.APA, A.P. DSM - Diagnostic and statistical manual of mental

disorders - fifth edition. Washington DC: American Psychiatric

Publishing, 2013.
4.Lzrescu M, Niretean A. Tulburrile de personalitate. Iasi: Editura
Polirom, 2007.
5.American Psychiatric Association. Diagnostic and statistical manual
of mental disorders (4th ed., text rev.). Washington, DC: Author, 2000.

***

REVIEW ARTICLES

ANIMAL ASSISTED THERAPY- BENEFITS FOR

PATIENTS
Ramona L Punescu1, Alina S Rusu2, Anca Zgrian3, Veronica ut4,
George Mooia5, Ioana V Micluia6
Abstract:
A substantial amount of recent research highlighted the
health benefits of human-animal interactions. Animal
assisted therapies that included pets (cats, dogs), horses
and dolphins were conducted in medical and non medical
facilities (prisons, veteran's shelters, etc). Proven benefits
are of physiological and psychological nature.
Physiological benefits include improvement in blood
pressure and heart rate. Depression, anxiety and cognitive
functions are the most important symptoms that may
benefit for animal assisted therapy.
Key words: animal-assisted therapy, depression, anxiety.

INTRODUCTION
Animal assisted therapy (AAT) involves an
interaction between patients and a certified trained animal,
which purpose is to facilitate the patients' progress toward
a therapeutic goal.
Delta Society, one of the most important organizations
involved in the certification of therapy animals in USA
defined animal assisted therapy as a goal directed
intervention in which an animal that meets specific criteria
is an integral part of the treatment process. AAT is directed
and/or delivered by a health/service professional with
specialized expertise and within the scope of his/her
profession. Key features include: specific goals and
objectives for each individual and measure progress.
Animal assisted activities (AAA) are defined by the same
organization, as activities that provide opportunities for
motivational, educational, recreational and/or therapeutic
benefits to enhance quality of life. AAA are delivered in a
variety of environments by specially trained professionals
and/or volunteers, in association with animals that meet
specific criteria (1).
The goal of AAT is to improve a patient's social,
emotional, or cognitive functioning. A therapist who
brings along a pet may be viewed as being less threatening,
increasing the rapport between patient and therapist (2).
Wilson's, 1984 (3) biophilia hypothesis is based on the
premise that our attachment and interest in animals stems
from the strong possibility that human survival was partly
dependent on signals from animals in the environment

indicating safety or threat. The biophilia hypothesis

suggests that now, if we see animals at rest or in a peaceful
state, this may signal to us safety, security and feelings of
well-being which in turn may trigger a state where
personal change and healing are possible. (3). The earliest
reported use of AAT for the mentally ill took place in the
late 18th century at the York Retreat in England, led by
William Tuke (4). Patients at this facility were allowed to
wander the grounds which contained a population of
small domestic animals. These were believed to be
effective tools for socialization. In 1860, the Bethlem
Hospital in England followed the same trend and added
animals to the ward, greatly influencing the morale of the
patients living there (5).
Animals can be used in a variety of settings such as
prisons, nursing homes, mental institutions and hospitals.
Assistance dogs can also assist people with many
different disabilities; they are capable of assisting certain
life activities and help the individuals navigate outside of
the home (6). In the last decades AAT has received a
growing interest and it has been used in several medical
areas. There are studied involving canine assisted therapy
conducted in cardiology departments, pediatric clinics,
pain management clinics, emergency rooms, psychiatry
clinics, etc. The documented benefits of AAT include
improved physical, emotional, cognitive, and social
functioning; reduced blood pressure and triglyceride
levels; and even reduced cardiovascular morbidity and
mortality (7).

1
Assistant Professor, Psychiatry Department, University of Medicine and Pharmacy "Iuliu Haieganu" Cluj-Napoca, Romania. Correspondence:Ramona
Punescu, Victor Babe Street no. 8, 400012, Cluj Napoca, Romania. Phone:+40745-502-649; E-mail: ramonaboia@yahoo.com
2
Associate Professor, Department of Special Education, Faculty of Psychology and Sciences of Education, Babes-Bolyai University, Cluj Napoca
3
Psychologist''Dog Assist Association
4
Psychologist, '' Dog Assist Association
5
President '' Dog Assist Association
6
Professor Doctor, Head of Psychiatry Department, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca
Received June 27, 2014, Revised July 31, 2014, Accepted August 29, 2014

10

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

Psychiatric patients benefit by reduced stress. Patients
with heart failure have lower epinephrine and
norepinephrine levels, with systolic pulmonary artery and
pulmonary capillary wedge pressure reductions after AAT
(5).
ANIMAL ASSISTED THERAPY IN MEDICAL
FIELDS
Animal assisted therapy has already proven its
efficacy as reported by clinical studies. Thus, several
studies conducted in cardiology departments showed a
decrease in blood pressure and heart rate for the
participants after the interaction with trained animals and
an increase in peripheral skin temperature (8, 9, 10). In one
study, (11) patients who were pet owners with long-term
animal exposure had lower blood pressure, heart rate, and
plasma rennin activity in response to mental stressors
(mathematical subtraction, speech) than did patients who
were not pet owners. In patients who survived myocardial
infarction, the risk for cardiovascular disease, morbidity,
and mortality 1 year after the infarction was lower in those
who were pet owners than in those who were not (12, 13).
In the Cardiac Arrhythmia Suppression Trial, dog
ownership was a significant independent predictor of
survival in patients 1 year after acute myocardial
infarction. These data support the hypothesis that excess
activity of the sympathetic nervous system due to both
physiological and psychological stress can be reduced by
AAT.
Patients with advanced heart failure are
threatened by many physiological and psychological
stressors (14, 15). Physiological stressors include the
activation of the neuroendocrine cascade, most likely
triggered by excitation of the sympathetic nervous system
(16). In a patient with heart failure, the presence of a nonthreatening stimulus such as a dog could relax the patient
by lowering the patient's state of arousal and reduce
neurohormonal activation caused by over activity of the
sympathetic nervous system (17, 18).
A recent study conduced by Cole et al (19)
assessed 76 patients with a diagnosis of advanced heart
failure. The aim of the study was to determine whether the
interaction between patients and therapy dogs improves
hemodynamic measures, lowers neurohormone levels,
and decreases state anxiety. The patients were divided into
three groups: the first group received the visit of a
volunteer, in the second group the patients were asked to
relax quietly in the bed, whereas the third group received a
visit form a trained therapy dog. For all groups relaxation
interventions lasted 12 minutes. The physiological
variables (blood pressure, heart rate, cardiac index, SVR,
epinephrine level, and norepinephrine level) were
assessed 3 times for all groups. Results showed that
animal-assisted therapy improves cardiopulmonary
pressures, neurohormone levels, and anxiety in patients
hospitalized with heart failure. The review of Wolff et al
(20) highlighted the positive effects of human-animal
interaction on the cardiovascular system and on the
improved survival after a myocardial infarct for pet
owners. It also emphases the importance for further
research in order to the complex elucidate physiological
mechanism underlying these benefits.
Dog assisted therapy's potential benefits were
also assessed in several pain management clinics. A study

conducted by Marcus et al (21) included two hundred

ninety-five therapy dog visits (235 with patients, 34
family/friends, and 26 clinic staff). Participants were able
to spend the waiting time in the clinic with a certified
therapy dog instead of waiting in the outpatient waiting
area. Self-reported pain, fatigue, and emotional distress
were recorded using 11-point numeric rating scales before
and after the therapy dog visit or waiting room time.
Results showed that therapy dog visits in an outpatient
setting provided significant reduction in pain and
emotional distress for chronic pain patients. Therapy dog
visits were also able to improve emotional distress and
feelings of well-being in family and friends
accompanying patients to appointments and clinic staff
(21). Pain relief interventions using AAT were made in
several pediatric centers. Braun et al (22) investigated the
change in pain and vital signs in an acute care pediatric
center for children aged 3-17. The patients were divided
into two groups: the first one (n=18) received AAT, while
the second one (n=39) did not. The results provided strong
evidence that AAT can reduce pain in children up to four
times more than for the children who did not interacted
with animals. The pain reduction felt by the children after
15 minutes of interaction with a dog was comparable with
the use of oral acetaminophen with and without codeine in
adults (22). In another study, Sobo et al (23) included 25
children aged 5 to 18 who underwent surgery and
experienced post operative pain. Participants were offered
one time visit form a therapy certified dog. The study
findings suggested that dog assisted therapy may be useful
as an adjuvant to the traditional pain treatment for children
(23). Other medical fields were dog assisted therapy was
successfully used were emergency departments (24) and
military medicine (25).
ANIMAL ASSISTED THERAPY IN PSYCHIATRY
Anxiety disorders and anxiety symptoms were
among the first psychiatric fields where animal assisted
therapy was used. Braker et al (5) conducted a study that
included 230 patients with different psychiatric disorders,
referred for therapeutic recreation sessions. A pre- and
post treatment crossover study design was used to
compare the effects of a single animal-assisted therapy
session with those of a single regularly scheduled
therapeutic recreation session. Before and after
participating in the two types of sessions, subjects
completed the state scale of the State-Trait Anxiety
Inventory, a self-report measure of anxiety currently felt.
The results revealed a statistically significant reduction in
anxiety scores after the animal-assisted therapy session
for patients with psychotic disorders, mood disorders, and
other disorders, and after the therapeutic recreation
session for patients with mood disorders (5). The same
author, in a 2003 study tried to determine weather animalassisted therapy (AAT) is associated with reductions in
fear, anxiety, and depression in psychiatric patients before
electroconvulsive therapy (ECT). In the study, 35 patients
were assigned on alternate days to the treatment condition,
consisting of a 15-minute AAT session, and the standard
(comparison) condition, consisting of 15 minutes with
magazines. Visual analogue scales were used to measure
anxiety, fear, and depression before and after treatment
and standard conditions. The results highlighted the fact
that animal-assisted therapy may have a useful role in
11

Ramona L Punescu, Alina S Rusu, Anca Zgrian, Veronica ut, George Mooia, Ioana V Micluia: Animal Assisted
Therapy- Benefits For Patients
psychiatric and medical therapies in which the therapeutic
procedure is inherently fear-inducing or has a negative
societal perception (26). In another study with twelve
acutely depressed patients, the authors measured state
anxiety with the State-Trait Anxiety Inventory (STAI), a
brief, easy-to-administer self-report measure that is
widely used in research and clinical practice. The STAI
state score was significantly reduced after the presence of
a dog. This finding suggests that animal-assisted therapy
causes highly significant reductions of state anxiety.
Presence of dogs may offer an additional therapeutic
benefit that might decrease anxiety and enhance
psychotherapeutic strategies and motivation of patients
and therapists (27). The recent study of Lang et al (28)
included 14 acute schizophrenic patients. Each patient had
to complete PANSS and the Spielberger State-Trait
Anxiety Inventory before the canine sessions. STAI was
completed again after the therapy. Two half hour sessions
were conducted with each patient. The
psychotherapeutically approach consisted of a 30 minutes
interaction with a dog and research assistant. During the
control session the patients were assigned to a 30 minutes
walk with the same research assistant. Both sessions took
place in the same quiet room at approximately the same
hour and the interval between the two sessions was one
day. Results of the study showed reduced anxiety in acute
schizophrenic patients as demonstrated by a significant
decrease in STAI scores after the dog assisted session (28).
The reduction of anxiety may be explained by evident
changes in stress responsive biological parameters like
cortisol and dopamine levels, blood pressure and heart
rate, as observed after a 15 minutes interaction between
certified therapeutically dogs and volunteers (29). The
study of Chu et al (30) aimed of to evaluate the effects of
animal-assisted activity on self-esteem, control over
activities of daily living, and other psycho-physiological
aspects among inpatients with schizophrenia. Thirty
participants were randomly assigned to either the
treatment or control group. A weekly animal-assisted
activity program was arranged for patients in the treatment
group for 2 months. A questionnaire assessing selfesteem, self-determination, social support, and
psychiatric symptoms was completed the week before and
the week after the animal-assisted activity. Compared
with the control group, the treatment group showed
significant improvement on all measures except for social
support and negative psychiatric symptoms. The results of
this study showed that animal-assisted activity can
promote significant improvements in many clinical
aspects among inpatients with schizophrenia. Therefore,
animal-assisted activity should be integrated into the
treatment of institutionalized patients with schizophrenia
(30).
Another psychiatric domain where animal assisted
therapy was applied is represented by the pathology of
elderly. Several studies made upon patients with dementia
were published during the last decade. Thus, the study of
Richeson (31) focused on animal assisted therapy on
agitated behaviors and social interventions for patients
diagnosed with dementia. The design of the study was
meant to test several hypotheses: if the effects of AAT can
decrease agitated behavior in tested patients; if agitated
behavior would suffer an increase after testing until follow
up; if patients undergoing AAT would increase their social
12

interactions and if AAT could decrease the need for

medication. The study participants had to meet several
including criteria among witch an established diagnosis of
dementia with a MMSE score <15, previous documented
agitated comportment, past interest in animals and no
allergies to dogs or dislike of the animals. Results of the
pilot study reported a decrease in agitation and a
significant improvement of social interactions for the
participants, even from the firs week of AAT. The fact that
there was not a relationship between the cognitive level
and the degree of agitated behavior suggested that AAT
may be an appropriate intervention for moderate to severe
cases of dementia. As far as the medication is concern, the
study showed no need of decreased medication for the
participants during AAT (31). The study of Motomura et al
(32) assessed a small sample of patients with dementia
(Alzheimer and vascular dementia) while undergoing
therapy with certified trained dogs. The aspects followed
were apathy, irritability, depressive symptoms and daily
living activities. The most significant change after AAT
was found on items for apathy scale. The recent review
conducted by Barnabei et al (33) in 2012 included a
number of 18 articles from literature with themes that
concentrated upon the relationship between animal
assisted interventions (AAI) and dementia patients. The
review highlighted the effect of AAI on behavioral and
psychological symptoms of dementia (BPSD), cognitive
functions and depressive symptoms for patients
diagnosed with dementia. For BPSD the studies included
reported a decrease in irritability and anxiety items on the
specific assessment instruments. Depressive symptoms
and emotional liability evaluated with Geriatric
Depression Scale were improved after animal-human
interactions. For cognitive functions assessed with Mini
Mental State Examination or Multidimensional
Observation Scale for Elderly Subjects, an improvement
was reported but it had no statistical significance. Only
one of the study included in the review found a significant
result (p<0,5) for spatial orientation, concentration and
abstract thinking (33).
Pediatric psychiatry is also a domain where AAT has
demonstrated its benefits. Katcher et al (34) examined the
effect of animal assisted therapy for children diagnosed
with attention deficit hyperactivity disorder (ADHD) and
conduct disorders. 50 children were randomly assigned to
an education program involving either interactions with
animals or outdoor activities. The results outlined that the
group of children who participated to animal assisted
interventions showed an increased attendance,
cooperation and engagement in learning activities, as well
as a decreased in antisocial and violent behavior (34).
Another good example for animal assisted therapy is seen
in children with autism spectrum disorder (ASD). The
review of O'Haire (35) discussed the results of two recent
studies that included this pathology. In one study children
were submitted to a 15 minutes therapy session with a dog,
a stuffed dog or a ball. The sessions were held for 15
weeks. Results reported increased playfulness, focus and
social awareness in the presence of the dog. The second
study included horses and therapeutic horseback ridings
for children with ASD for 12 weeks; its results indicated
an increased sensory and social motivation and decreased
inattention (35).

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

CONCLUSIONS
Animal assisted therapy has several benefits both
in medical and psychiatric fields. The interactions
between patients and trained animals resulted in lower
levels of anxiety, reduced agitation, increased cognitive
performances (attention), improved mood and increased
social skills.
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***

13

ORIGINAL ARTICLES

PERSONALITY DISORDERS AND PSYCHOTIC

DISORDERS CO-MORBIDITY IN FORENSIC
INPATIENTS
Monica D Moescu1, Alina V Ungureanu2, Magdalena Dragu3, Gabriela Costea 4
Abstract:
Background: Comorbid personality disorder and
psychotic disorders always represent a major challenge
for every day practice.
The aim of this study is to analyze the implications of dual
diagnosis of psychotic disorder and personality disorder
among forensic inpatients.
Method: It's a non-interventional study performed in
Spoca Forensic Psychiatry Hospital during 12 months.
Patients, diagnosed with schizophrenia or other psychotic
disorders, hospitalized in the forensic wards were screened
for personality disorder. We followed treatment received,
participation in occupational therapy, and occurrence of
violence during follow-up period. Participants were
assessed using PANSS, CGI-S and HCR-20 at baseline,
after 6 months and at the endpoint (12 months. Statistical
analysis was performed with SPSS 17.0. We used
information only from medical files. The design was
approved by the Ethical Board of SFPH.
Results: 50.7% from the final sample of 128 patients (101
male, 27 female) were diagnosed with PD. Most common
was antisocial PD (36.9%) followed by borderline PD and
mixed PD. We observed significant correlations (p<0.05)
between PD and alcohol use, antipsychotic combination
therapy, use of mood stabilizers, poor involvement in
occupational therapy, occurrence of violence. There were
no significant correlations between the types of PD and the
variables followed. The final sample was divided in 2
groups: with PD and without PD. The Mann-Whitney test
confirms correlations obtained from cross-tabulations.
There were differences between groups on clinical
improvement (mixed ANOVA): PANSS-T (p=0,032), CGIS (p=0,007), PANSS-EC (p=0.045) and on occurrence of
violence (Kaplan-Meier analysis: Log Rank=16,177, p
=.000.
Conclusions: Personality disorder, most often for cluster
B, is a quite common comorbid with psychotic disorder in
this forensic sample and is independently associated with
an increased risk of violent behaviour in psychosis. This
observation is important for risk assessment and risk
management in forensic inpatients. Further studies are
needed given the methodology limits of this study.
Key words: forensic psychiatry, schizophrenia,
personality.

MD, PhD, Psychiatry and for Safety Measures Hospital Sapoca, Buzau, Address: SPMS Sapoca, Buzau, Romania, 127540, phone: 0238528146 fax:
0238528474, md_mosescu@yahoo.com;
2
MD, Psychiatry and for Safety Measures Hospital Sapoca, Buzau, Romania
3
MD, PhD, Head of Department, Medical - Legal Service, Buzau County, Romania
4
MD, PhD, Forensic Psychiatry Department, National Medico-Legal Institute, Bucuresti, Romania
* SPMS Sapoca forensic psychiatric wards Ojasca, Unguriu, Buzu County
Received August 18, 2014, Revised September 30, 2014, Accepted October 27, 2014

14

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

INTRODUCTION
Personality disorders (PDs) are common,
debilitating psychiatric conditions that have enormous
costs to patients and their family members, and more
broadly, to society. Unfortunately, these conditions are
also widely misunderstood and misdiagnosed (1). With
respect to prognosis, PD may be associated with increased
risk for criminal and violent behaviour, as well as with
poor response to psychosocial rehabilitation and crime
reduction programs (2). More than half of those with PD
also had an axis 1 disorder (3) and patients with co-morbid
psychotic disorders and personality disorders are among
the heaviest users of psychiatric services (4) and forensic
services also. On the other hand, the number of forensic
psychiatric inpatients has been growing markedly and risk
assessment and management of patients with severe
mental illness are increasing priorities for mental health
services (5).
There is few data in literature relating to those with
schizophrenia (or other schizophrenia spectrum disorder)
also diagnosed with personality disorder who committed a
criminal act (more often violent) and are referred to
forensic psychiatric services (compulsory hospitalization
as medical safety measures according Romanian law).
The primary objective of this study is to analyze
the implications of PD co-morbid with schizophrenia (or
other schizophrenia spectrum disorder) on the clinical
course and treatment received and on violent behaviour in
patients admitted to implement safety measures of a
medical nature. The secondary objective is to provide
epidemiological data essential for the development of
forensic mental health services strategy.
MATERIAL AND METHOD
Participants. Procedure
The study is a longitudinal and observational,
non-interventional one, accomplished by Sapoca PSMH
(Psychiatry and Safety Measures Hospital) during 12
months in 2008-2009. There were included in the study
patients hospitalized in forensic psychiatric wards
diagnosed with schizophrenia or other schizophrenia
spectrum disorder: F20-F29 according to ICD 10
(International Classification and Statistics of Diseases and
Related Health Problems, Revision 10), aged 18-65 years
who have signed consent for participation. There were
excluded patients with length of stay longer than 2 years.
The baseline data were obtained from medical and legal
documents. Patients were evaluated and have been applied
scales: SCID-II (Structured Clinical Interview for
Personality Disorders Clinical), PANSS (Positive and
Negative Symptom Scale - Scale of positive and negative
symptoms in schizophrenia), CGI-S (Clinical Global
Impression - Clinical Global Impression -severity) and
HCR-20 (Historical Clinical and Risk Management).
Information used was: socio-demographic data (age,
gender, origin, education, and occupation), psychiatric,
forensic and criminal history, alcohol use, offense. The
patients were evaluated at baseline, at 6 months and 12
months (end of study): PANSS, CGI-S, and HCR-20.
During the study period we followed the
therapeutic plan (antipsychotics, mood stabilizers, and
occupational therapy - OT) and the interpersonal violent
behaviour.

Instruments
Psychotic disorder was diagnosed accordingly to
ICD-10 (6) and PD was assessed with semi-structured
interview SCID-II (7) only from a categorical perspective
and not dimensional and the diagnosis was based on ICD10 (F60-F61). To evaluate the clinical course we used
PANSS (positive, negative, general and total scores,
excited- component score) and CGI-S (8, 9).
To assess the risk of violence it was used HCR20, scores (subscales: H, C, R and total) and violence risk
assessed (low, medium and high). The final risk
assessment of violence was made following the
discussions of the two independent assessors with
accredited training (10). The HCR-20 was used only for
research purposes and the proposal to change the safety
measure by the forensic psychiatric commission being
based on the current methodology (mainly clinical
judgment).
Violence in hospital was considered only if it had
been documented by medical staff and it was understood
as damaging to one or more persons that an attempt or
threat as described by the authors of the HCR-20 (10).
Statistical analysis of data was performed with SPSS 21.0.
(Statistical Package for Social Sciences) for Windows.
The tests used were chosen based on the type of variables: t
test for two independent samples (interval variables), chisquare test of association cross-tabulation (for nominal
and ordinal variables), correlational analysis, MannWhitney test, ANOVA test (repeated measures, mixed),
Kaplan-Meyer survival analysis.
Ethical Considerations
The study was non-interventional, data used
were collected only from medical and forensic records and
the three assessments of the study corresponded to
periodic assessments of forensic inpatients according to
the law. The therapeutic program was conducted by the
treating psychiatrist in the patient's best interest.
Methodology of the study and informed consent model
were approved by Ethical Board of Sapoca PSMH.
Throughout the study it was considered legal and privacy
rights of the volunteer participants. The study was
conducted on a vulnerable population.
Methodological limitations
There are considered as methodological
limitations: the small number of participants and the lack
of validation on Romanian population of assessment tools
used. Evaluation of violent behaviour and participation in
occupational therapy (OT) based on the information noted
in the observation sheets by untrained medical personnel
specifically for the study.
RESULTS
Participants
At screening the group of 128 subjects were
diagnosed with schizophrenia or other schizophrenia
spectrum disorder and 28 of them had a diagnosis of PD.
At baseline assessment there were identified 65 subjects
with PD and 63 without PD. 109 subjects completed the
study (53 with PD and 56 without PD); the reasons for
non-completion (19 cases) were different (medical, legal,
withdrawal of consent, unauthorized leaving hospital)
(Table no.1).

15

Monica D Moescu, Alina V Ungureanu, Magdalena Dragu, Gabriela Costea: Personality Disorders And Psychotic
Disorders Co-morbidity In Forensic Inpatients

No.
Sex

male
female
Mean age (SD)

Total
Baseline
128
101
27
38.16
(10,269)

Endpoint
109
86
23
38.59
(10.595)

PD
Baseline
65 (50.7%)
49
16
31.20
(7.750)

Endpoint
53(48.6%)
41
12
32.34
(8.00)

No PD
Baseline
63 (49.2%)
52
11
43.86 (12.148)

Endpoint
56(51.4%)
45
11
44.50
(12.59)

Table 1. Group and subgroups: distribution on sex and mean age

At baseline the most commonly diagnosed was
antisocial PD (36.9%) followed by borderline PD and
mixed PD, noting important differences towards
screening (diagnosis established by initial forensic
expertise) (Table no.2).
PD
Antisocial PD
Borderline PD
Mixed PD
Narcissistic PD
Paranoid PD
Schizoid PD
Anankastic PD

Baseline
24
15
15
3
4
2
2

Total

Screening
16
4
8
0
0
0
0
65

without PD, the mean age was lower in the PD group with
statistical significance: t (104.7) = - 7.003, p = .000.
Groups are similar in terms of psychopathology
and clinical symptoms, that there were no significant
differences (p>0.05) for all the scales and subscales scores
obtained (PANSS, CGI, HCR-20). PD significantly
correlated with the risk of violence assessed at baseline: 2
(2) = 7.81, p = 0.02. PD is associated with alcohol
consumption: 2 (1) = 37.611, p = 0.000, phi coefficient =
0.542, the relationship between the two variables is strong
(according to Cohen, 1988); likehood of alcohol use (OR)
is 12.5 times higher in PD group than no PD group (95%
CI, 5.2-30.2) (Figure no. 2).

28

Table 2. Type of PD's - baseline vs. screening

We observe dominant PDs from the B cluster
(antisocial, borderline, narcissistic - 64.6%) while the PDs
from A cluster (paranoid, schizoid, schizotypal)
represents 9.2% and C cluster (anankastic, dependent,
avoidant) only 3% (Figure 1).
PD clusters at baseline
cluster A 9%
mixed PD 23%

Figure 2. The relationship between PD and alcohol use for

final sample
cluster C 3%

cluster B 65%

Figure 1. A pie-chart illustrating the distribution of PD

clusters at baseline
Comparative presentation of lots (PD vs. no PD)
The two samples were analyzed by independent
t-test (age, scores, length of stay) and chi-square test (sex,
occupation, education, area of origin, marital status,
alcohol use, psychiatric, forensic and criminal history,
violence risk). Subjects with PD were younger than those
16

PD significantly associated with criminal

records: 2 (1) = 28.646, p = 0.000 and forensic history: 2
(1) = 38.763, p = 0.000. PD is not significantly statistically
associated with: gender, rural origin, marital status,
occupation, education and psychiatric history (p>0.05).
In the group with PD violent index offenses are
more common than in the group without PD (45 vs. 34) but
the difference is not statistically significant (p = 0.116).
Murder is more common in the group without PD (21 vs.
15) also without statistical significance (p = 0.358). PD
type mattered, with statistically significance (Kendall
tau_b correlation), for criminal records (0.447, p = 0.000)
and for participation in occupational therapy (-0.228, p =
0.047) and for repeated violence (0.371, p = 0.001). From
the descriptive analysis it was observed that patients with
antisocial PD often had a criminal history and those with
borderline PD paticipated less at occupational therapy.
Repeated violence during the study was more common

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

improvement is only significant for PANSS_N,
PANSS_G, PANSS_EC, and PANSS_T. There is no
significance for PANSS_P, CGI-S, HCR_C, and HCR_C.
Post-hoc tests confirm the statistic significance presented.
At the independent t test was significant difference (p
<0.05) between the two groups for all scores followed,
both at 6 months and at endpoint (Table no. 5).

those with antisocial PD and mixed PD. There were no

statistically significant correlations between types of PD
and other variables.
The clinical course
In both groups (with and without PD), clinical
improvement was statistically significant (p=0.000,
ANOVA test combined), for all scores, at 6 months and 12
months also. The improvement between baseline and
endpoint differ significantly between groups (with and
without PD) according the effect of interaction time*PD,
this means the improvement is significantly better in the
group without TP (Table no. 3). Table no. 4 (Tests of
Between-Subjects Effects) show that the main effect of
PD is statistically significant for all scores, except
PANSS_N (negative) and PANSS_G (general).
Clinical improvement is significant for the first
six months of the study (0-6 months) for all scores while,
in the second period of 6 months (6-12 months),

PANSS_P
PANSS_N
PANSS_G
PANSS_T
PANSS_EC
CGI_S
HCR_R
HCR_C

df
1.45
1.49
1.38
1.41
1.46
1.63
1.39
1.42

F
5.49
9.91
12.44
17.30
12.58
6.80
6.63
5.94

P
0.011
0.000
0.000
0.000
0.000
0.003
0.008
0.005

Table 3. Results to ANOVA repetead measures

Type III Sum of

Source

Measure

df

Mean Square

Sig.

Squares

Intercept

PANSS_P

130390.546

130390.546

1822.197

.000

PANSS_N

101073.152

101073.152

2073.029

.000

PANSS_G

351195.979

351195.979

2299.532

.000

PANSS_T

1617053.677

1617053.677

3474.133

.000

28985.124

28985.124

1826.708

.000

8466.874

8466.874

11694.143

.000

21972.786

21972.786

6943.376

.000

PANSS_P

529.948

529.948

7.406

.008

PANSS_N

181.276

181.276

3.718

.057

PANSS_G

155.231

155.231

1.016

.316

PANSS_T

2395.484

2395.484

5.147

.025

PANSS_EC

71.504

71.504

4.506

.036

CGI

15.884

15.884

21.938

.000

HCR_C

29.808

29.808

9.419

.003

PANSS_EC
CGI
HCR_C

PD

Table 4. Tests of Between-Subjects Effects (ANOVA mixed) reflecting the influence of PD on clinical courseTable 5. Ttest results reflecting differences between groups (PD vs. no PD) on psihopathology and violence risk

PANSS_P
PANSS_N
PANSS_G
PANSS_T
PANSS_EC
CGI_S
HCR_C
HCR_R

Baseline (T0)
t
1.33
0.752
-0.756
-0.206
0.681
0.557
0.669
1.35

df
125.8
122.4
116.2
125.7
119.3
125.9
122.4
123.7

P
0.185
0.453
0.451
0.837
0.497
0.578
0.505
0.177

6 months (T1)
t
Df
3.56
125.9
2.38
125.2
0.92
126
2.8
122.5
2.88
126
2.92
122
2.88
126
3.1
124

p
.001
.019
0.358
.006
.008
.004
.005
.002

Final (T2)
t
df
3.85
106.7
3.78
96.4
3.08
104.7
4.36
105.3
4.15
107
4.78
106.9
3.23
103.1
3.73
107

p
.000
.000
.003
.000
.000
.000
.002
.000

Table 5. T-test results reflecting differences between groups (PD vs. no PD) on psihopathology and violence risk test

17

Monica D Moescu, Alina V Ungureanu, Magdalena Dragu, Gabriela Costea: Personality Disorders And Psychotic
Disorders Co-morbidity In Forensic Inpatients
Violent behaviour
PD significantly correlated with violence
(Pearson correlation): 0.415, p=.000 and there were
statistically significant differences between the 2 groups
on violent behaviour during the study: 2 (1) =22.056, p =
0.000 (Figure 3). Observations were confirmed by
Kaplan-Meier survival analysis: Log Rank = 16.177, p =
.000 (table no.6) Patients with PD had a seven times higher
risk of having a hospital violent behaviour (OR = 7.35,
95% CI, 3.02-17.90) (Figure 4).

PD correlated significantly with repeated violence: 2 (1)

= 10.743, p = 0.001; those with PD have a 3.5 times higher
risk for repeated violence (OR=3.5, 95% CI, 1.63-7.62)
Treatment plan
There were statistically significant differences
between groups regarding the therapeutic plan (chi-square
test). PD significantly correlated with: the use of
antipsychotics in combination, the use of mood stabilizers
and low participation in OT (table no. 7).
Pearson chi-square
Ocup_therapy
Ocup_therapy systematic
Mood stabilizers
Antipsychotics

2
23,201
11.883
16,452
19.915

df
1
2
1
2

P
0.000
0.003
0.000
0.000

Table 7. Differences on treatment plan

Figure 3. A bar chart reflecting relationship between PD

and hospital violent behaviour

PD
PD
No
PD

Overall Comparisons
Chidf
Square
Log Rank (Mantel-Cox) 3.150 1
19.649 1
Log Rank (Mantel-Cox)

Sig.
.076
.000

Table 6. Results of Kaplan Meyer Analyse reflecting

occurence of violence

Figure 4. Kaplan Meier survival analysis demonstrated

poorer survival (no violence) in PD group
18

Participation in OT is negatively correlated with

violence, which means that participation in OT can be
considered protective factor for the occurrence of violence
only in the group without PD. Only in the group without
PD, chi-square test showed a statistical significance
between participation in OT and violent behaviour: 2(1)
= 12.270, p = 0.000, an observation confirmed by KaplanMeyer survival analysis.
In the group without PD, participation in OT is an
independent factor with statistical significance to clinical
improvement in subscales: PANSS_ P (p = 0.002),
HCR_R (p = 0.000) and HCR_C (p = 0.000), but in the
group without co-morbid PD, participation in OT does not
correlate with clinical improvement than for HCR_C (p =
0.024). Note that patients with schizophrenia and PD
participating in OT have a better evolution in terms of
positive symptoms and risk factors. PD correlates with
poor therapeutic compliance and even with therapeutic
resistance. Therapeutic compliance is seen better by
participating in OT because pharmacological treatment
administration is strictly monitored by medical staff.
Patients with psychosis and co-morbid PD were
more often treated with a combination of antipsychotics
than with monotherapy but without statistical
significance. Type of antipsychotic drug used (first
generation, second generation, combination) does not
matter in clinical outcome for patients regardless of the
presence of PD. These results are confirmed in mixed
ANOVA: there is interaction effect, time*antipsychotics,
only for PANSS_EC (p=.012) and only for psychotic PD
patients. There isn't any interaction effect with statistical
significance in the group without PD. Significant
difference was observed only for PANSS-EC subscale (p
= 0.000) in the PD group which means that the use of
antipsychotics in combination was an independent factor
for decrease PANSS-EC score. This observation supports
the complexity of therapy necessary for these patients (PD
co-morbid schizophrenia) with the rising cost of
hospitalization.
Risk assessment
PD mattered significantly for the discharge
proposal: 2(1)=7.07, p=.008. Patients without PD had a
higher likelihood (OR=3.3, 95% CI, 1.33-8.23) of being
proposed for discharge compared to those with PD co-

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

morbid schizophrenia.
There was a statistically significant correlation
between the PD and HCR-20 risk-assessed (low, medium,
high): 2 (2) = 7.81, p = 0.02.
In terms of predictive validity for violent
behaviour we analyzed HCR-20 risk assessed, HCR-20
scores (total, C, R), PANSS_EC and observed an average
predictivity (0.7 to 0.75) for the group without PD and a
low predictivity for the group with PD (table no.8).

HCR_risk_assess
HCR_R
HCR_C
HCR_total_score
PANSS_EC

AUC
PD
0.712
0.445
0.546
0.654
0.467

No PD
0.735
0.758
0.715
0.735
0.704

Total
0.725
0.666
0.647
0.703
0.623

Table 8. ROC analisys for violence prediction

DISCUSSION
The first observation is related to underdiagnosis of PD in forensic practice: only 28 (21.8%)
subjects were diagnosed with PD (generally antisocial PD
- 16) co-morbid schizophrenia (or other schizophrenia
spectrum disorder) compared to 65 (50.7%) diagnosed at
screening. In 5 cases it was diagnosed another type of PD.
Regarding the diagnosis of schizophrenia (or other
schizophrenia spectrum disorder) there were only 22 cases
where the screening diagnosis was different, but in the
same spectrum: F20-F29.
Epidemiological data obtained correspond to the
literature regarding prevalence PD and co-morbidity with
psychotic disorders and prevalence of cluster B PD
(antisocial, borderline, histrionic, and narcissistic) but
also in terms of: gender, average age, alcohol
consumption. Review of the literature reveals limitations
in comparing results among previous studies about PD,
possibly due to variability in the types of populations,
measures, and patterns of analysis. This was demonstrated
by widely differing prevalence rates of personality
disorders (11).
In sharp contrast to our results, a large proportion
of patients in Dutch forensic hospitals have a PD without a
concomitant major mental disorder (12) but, the same,
cluster B PD is predominant: in a sample of 94 patients,
66% fulfilled diagnostic criteria for a cluster B (13). In
other sample of 39 patients: 87 % received a diagnosis of
PD, most often from cluster B (14). In a German forensic
sample (141), 51 have one PD and only 18 have psychosis
and more than half of the patients have had a drug or
alcohol problem (15). In a sample of 162 forensic inpatients from the same Romanian Forensic Hospital
(PSMH Sapoca), 58 (36%) were found with one PD and
39 (24%) were diagnosed with schizophrenia and comorbid PD (16).
In secure hospitals from UK: 88% are men, mean
age was 37, 86% had schizophrenia and 85% had
problematic use of alcohol ( medium security unit) and
mean age was 40 years, 61% had schizophrenia, 45% PD
and 10% are dually classified (high security unit) (17).
Mean age (31.2 years) was similar with those of Romanian
forensic sample (35.2 years) (16) and German forensic
patients (36.5 years) (15).

There are few data about offenses: patients from

German sample have different crime backgrounds (54%
sexual offenders, 27% battery or murder) (15) and in UK
medium secure unit: 25% murder/attempting murder,
29% wounding, 20% assault and 10% sexual offence (17).
In our study, violent offence was more frequent in group
with schizophrenia and co-morbid PD (69%) than without
PD (54%) and it is remarkable the absence of sexual
offenders in our sample, probably because of the lack of
victim's courage to recognize their problem.
Alcohol consumption is frequently associated
with PD and schizophrenia and it is an independent risk
factor for violence seen in the literature data. There is an
association of homicide with mental disorder, particularly
with schizophrenia, antisocial personality disorder and
drug or alcohol abuse (18). Cluster B PD is, undoubtedly,
the most related to criminal and it is the most connected to
alcohol/drug abuse, which is a clearly precipitating factor
of violence (19) and antisocial PD is a risk factor for
developing problem drinking and often antisocial PD
develops a few years before the drinking (20). Mihailescu
and Mihailescu, 2007 (21) showed that marital status,
alcohol abuse, previous psychiatric hospitalizations were
predictors of violent behaviour in schizophrenia (21).
PD co-morbid schizophrenia was associated
with an increased risk for violence and a more complex
treatment. PD relationship with violence is complex
because of the variety of PD, high co-morbidities and the
difficulty of establishing causality (22). Personality
dysfunction is often a co-morbid condition, making it
difficult to determine direct causation. Although comorbidity as a clinical concept can increase
understanding, in the legal arena it can lead to confusion
by making apportionment of responsibility or fault more
difficult (23).
Co-morbid PD are also likely to be independent
risk factors for violence in individuals with schizophrenia
(24,25) and personality pathology can be a significant
predictor of aggression in patients with schizophrenia
(26). The risk of violence in patients with schizophrenia is
significantly increased by association with antisocial PD
and borderline PD (27) and co-occurrence of
schizophrenia and borderline PD is not infrequent and that
borderline PD has a significant negative longitudinal
impact on the course and outcome of patients with
schizophrenia (28). In most respects, offenders with
schizophrenia and high levels of psychopathic traits seem
to be similar to psychopathic offenders without psychotic
illness, which has implications for early intervention and
management (29). Co-morbidities are frequently
implicated in violent behaviour of psychotic patients, and
their detection and treatment are therefore of primary
importance. Psychosocial treatments are necessary
components of the management of violence in psychosis
(30).
Better predictivity in schizophrenic group
without PD raises questions considering that psychopathy
is an H subscale factor (HCR-20) and, the same, the
differences from international observations on the HCR20 violence predictivity (10) but can be explained by
methodological limitations of the study. PD correlates
with more frequent use of combination of antipsychotics
and mood stabilizers and low participation in occupational
therapy which resulted in a limited clinical improvement
19

Monica D Moescu, Alina V Ungureanu, Magdalena Dragu, Gabriela Costea: Personality Disorders And Psychotic
Disorders Co-morbidity In Forensic Inpatients
for those with PD and schizophrenia. Non-completion of
treatment of PD has been associated with a number of
negative consequences, including retention of criminal
attitudes (31), poor global functioning and higher rates of
hospitalization (32). Evidence of effective therapeutic
programs for PD is limited especially regarding long-term
outcomes (including antisocial behaviour): cognitivebehavioural interventions have the best evidence base and
pharmacological interventions using mood stabilizers and
atypical antipsychotics may be effective for some
symptoms of personality disorders (33). In addition to
relapse prevention and psychiatric symptom relief, the
benefits of antipsychotics and mood stabilisers might also
include reductions in the rates of violent crime (34). There
are 3 inevitable problems related to treatment of violent
patients with PD: PD are egosyntonic and PD patients not
accessing psychiatric services only in cases of
emergency/crisis or when associated another mental
disorder (35).
The Dutch forensic mental health field focus on
treatment of dynamic risk factors for new offenses, of
which PD is one (12) and the UK is recognising the
importance of mental health awareness and reduction of
stigma, and has begun to integrate access to treatments
with employment services (36).
All these issues outline wavy evolution marked
by non-compliance and treatment resistance. These
problems lead to prolongation of hospitalization and to
increased costs during hospitalization. In this context, we
believe that assessment and accurate diagnosis as both a
psychotic disorder and a co-morbid personality disorder it
would facilitate access to complex individualized
treatment programs. Best specialized mental health
services for people with PD and schizophrenia may be
provided in specific treatment units for PD patients. The
literature discussing where forensic patients with PD can
be treated: forensic hospitals or prisons (17).
PD people are heterogeneous in terms of variety,
consistency and intensity of their symptoms (35), problem
whose solution is tried with categorical and dimensional
hybrid model proposed by DSM 5. The new model
contribute to greater understanding of the causes and
treatments of personality disorders and, as clinicians
become more familiar with the new PD model, patients are
likely to receive more accurate assessments and
diagnoses, leading to improved clinical care (1).
CONCLUSIONS
The study achieved its primary objective of
identifying the implications of PD co-morbid with
schizophrenia (or other schizophrenia spectrum
disorders) on forensic patients: PD is associated with
alcohol use, violent behaviour and the need for complex
and individualized therapeutic programs. These
observations are important for assessing and managing
violence risk in hospitalized patients assisted with medical
safety measures (forensic patients). The survey data
showed that PD co-morbidity is common in schizophrenia
and most often is a cluster B PD and thus was fulfilled and
the secondary endpoint to provide epidemiological data
necessary development strategies forensic mental health
services. Given the ethical and legal implications of
judicial psychiatry is vital to providing quality services to
20

ensure a balance between individual freedom and public

safety interests. Further studies are needed, given the
methodological limitations of this study.
ABBREVIATIONS
PD Personality disorder
PSMH Psychiatry and Safety Measures Hospital
ICD-10 - International Classification and Statistics of
Diseases and Related Health Problems, Revision 10
SCID II - Structured Clinical Interview for Personality
Disorders Clinical
PANSS - Positive and Negative Symptom Scale Scale of
positive and negative symptoms in schizophrenia
CGI-S - Clinical Global Impression - severity
PANSS_EC - excited-component of PANSS
PANSS_P PANSS positive score
PANSS_N PANSS negative score
PANSS_G PANSS general psychopathology scale
PANSS_T PANSS total score
CGI-S - Clinical Global Impression severity
HCR-20 - Historical Clinical and Risk Management
SPSS Statistical Package for Social Sciences
ANOVA analysis of variance
SD standard deviation
OT occupational therapy
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2.Hart SD. Commentary: The Forensic Relevance of Personality
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10.Douglas KS, Guy LS, Weir J. HCR-20 violence risk assessment
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11.Adel A, Grimm G, Neil L, Mogge T. Sharp Prevalence of Personality
Disorders at a Rural State Psychiatric Hospital. J Rural Community
Psychol 2006; E9:1.
12.De Ruiter C, Robert L. Trestman Prevalence and Treatment of
Personality Disorders in Dutch Forensic Mental Health Services. J Am
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13.Hildebrand M, de Ruiter C. PCL-R psychopathy and its relation to
DSM-IV Axis I and Axis II disorders in a sample of male forensic
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14.Timmerman IGH, Emmelkamp PMG. The prevalence and
comorbidity of Axis I and Axis II disorders in a group of forensic patients.
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16.Mosescu M, Stefanescu A. Personality disorders and forensic inpatients, paper at 8th European Congress of International Society for the
Study of Personality Disorders, Targu Mures, 2008.

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17.Sivaprasad L. Treatment and Outcomes in Secure Care. In: Clark T
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19.Esbec E, Echebura E. Violence and personality disorders: clinical
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28.Bahorik AL, Eack SM. Examining the course and outcome of
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***

21

ORIGINAL ARTICLES

ADAPTAREA ROMNEASCA A PROBEI DE

MEMORIE EPISODIC CU CODURI SEMANTICE
RI-48
Cristina Popescu, Ctlina Tudose, Anca Niculi
Abstract:
Background: Episodic memory impairment has been
recognised as the hallmark symptom of Alzheimer disease
(AD).The occurrence of the retrieval difficulties when
encoding specificiy was optimised by coordinating
encoding and retrieval conditons is a specific marker of
AD. A group of Belgian and Swiss researchers have
developed a French version of the category cued recall
memory task (RI-48) and have proven its psychometric
properties, reliability, discriminative, concurrent and
predictive validity.
Methods: We adapted to the Romanian population the RI48. We kept the RI-48 structure, the number of semantic
categories and words. We analysed the psychometric
properties of the Romanian version of this task, RI-48-R.
Four groups of elderly people, differentiated in terms of
cognitive functioning, were included in the study:1.
normal cognitive functioning; 2. subjective memory
complaints; 3. mild cognitive impairment in AD; 4.
dementia in AD.
Results: The RI-48-R reliability was good (alpha = 0.89).
No ceiling effect was observed. The discriminative validity
of the RI-48-R was proved. There was a significant effect of
the diagnostic group on encoding and retrieval scores.
Multiple comparisons between groups revealed intergroups quantitative and qualitative differences, both in
terms of the encoding, as well as the retrieval.The
concurent validity of RI-48-R was proved.
Conclusions: Romanian adaptation of cued recall
memory task has adequate psychometric properties. By
applying it the AD specific deficits of encoding and
retrieval can be assessed.
Key words: episodic memory, cued recall task, Alzheimer's
disease.

22

Cristina Popescu, Ctlina Tudose, Anca Niculi: Adaptarea Romneasca A Probei De Memorie Episodic Cu Coduri
Semantice Ri-48
MMSE

N
N=23

AMS
N=30

TCU
N=97

D
N=
57

Analiza
de
varian

SEX:
feminin
(%)
Vrsta

15
(65,2%)

18
(60%)

61(62
,9%)

=1,35,
NS*

71,786,
3

72,47
5,06

72,13
7,13

Instruire

15,262,
26

14,37
2,04

14,28
2,54

35
(54,
7%)
74,0
46
,68
14,2
51
,6

N
1
29,7
0,56

AMS
2
29,03
1,16

TCU
3
28,35
1,41

D
4
24,672,53

Medie
abatere
standard
Mediana 30
29
29
25
Testul H
=83,97
KruskalWallis
Testul U 1 vs.2, 1vs.3, 1vs.4, 2vs.3, 2vs.4,
Mann3vs.4
Whitney
p<0,05, p<0,001

F=1,15,
p=0,32
F=2
p=0,11

N-Funcionare cognitiv normal, AMS-Acuze mnezice

subiective,
TCU-Tulburare cognitiv uoar, D - Demen
* NS- Diferene nesemnificative statistic

R-ACE-R

Scor total

N
Ma.s./Md
1
96,62,35/
97
180/
18
24,782,45/
25

AMS
Ma.s./Md
2
94,34,2/
95
17,970,3/
18
23,832,49/
24

TCU
Ma.s./Md
3
89,75,9/
90
17,60,7/
18
22,432,75/
23

Demen
Ma.s./Md
4
75,510,4/
75
161,99/
17
16,194,7/
16

Comparaii

H: =113.96, U:1vs3,
1vs4, 2vs3, 2vs4, 3vs4
Orientare TS
H: =73,68, U:1vs3, 1vs4,
2vs4, 3vs4
Memorie
H: = 95,58, U:1vs2,
1vs3, 1vs4, 2vs3, 2vs4 ,
3vs4
Fluen verbal 12,523,01/
12,073,34/
10,432,09/
7,793,31/
H =63,81, U:1vs3, 1vs4,
12
12
11
7
2vs3, 2vs4, 3vs4
Limbaj
25,31,15/
24,571,85/
23,652,37/
23,193,15/
H: =44,81, U:1vs3, 1vs4
26
25
24
24
2vs3, 2vs4, 2vs4
Vizuo-spaial
16,040,47/
15,870,43/
15,551,0/
14,372,27/
H =41,35 , U:1vs3, 2vs3,
16
16
16
15
2vs4,3vs4
N-Funcionare cognitiv normal, AMS-Acuze mnezice subiective, TCU- Tulburare cognitiv uoar, D Demen
. H: Testul H Kruskal-Wallis, U: Testul U Mann-Whitney
p<0,05, p<0,01, p<0,001

26

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

Variabila

EIM-C
EIM-G
ECIM2 repetari
ECIM
3 repetri

N
Ma.s.
Md
1
42,24,2
43
0,750,7
1
3,93,6
4
0

AMS
Ma.s
Md
2
41,43,6
42
1,31,6
1
4,43,3
3,5
0,060,2
0

TCU
Ma.s
Md
3
38,54,8
39
2,41,8
2
6,2/3,9
5
0,30,7
0

D
Ma.s
Md
4
30,66,8
32
3,92,8
4
19,65
6
2,64,46
1

Comparatii
inter- grupuri
H: =75,06 , U: 1vs2,1vs.3, 1vs.4, 2vs3,
2vs4, 3vs4
H: =45,48, U:1vs3, 1vs4, 2vs.4, 3vs4
H: =50,64, U:1vs3, 1vs4, 2vs4
H:=53,38, U: 1vs3, 1vs4, 2vs4, 3vs4

EIT-C

316,2
30,35,6
26,35,8
17,17,4
H:=61,39, U:1vs2, 1vs3, 1vs4, 2vs3,
30
28
26
19
2vs4, 3vs4
EITC- a
0,690,2
0,690,2
0,60,1
0,30,2
H:=45,61, U:1vs3, 1vs4, 2vs3, 2vs4,
0,65
0,64
0,56
0,42
3vs4
EITC-b
0,60,3
0,510,2
0,50,2
0,310,2
H: =27,2, U: 1vs3,1vs4, 2vs4, 3vs4
0,67
0,5
0,45
0,27
EIT-GR
2 2,2
2,63
3,43,3
4,94,08
H::=17,14, U: 1vs3,1vs4, 2vs4, 3vs4
1
2
3
3
N-Funcionare cognitiv normal, AMS-Acuze mnezice subiective, TCU- Tulburare cognitiv uoar, D - Demen
EIM-C-regsiri imediate corecte, EIM-G- regsiri imediate greite, EIT-C- regsiri ntrziate corecte, EITaregsire ntrziat, subscorul a, EIT-b regsire ntrziat, subscorul b, EIT-G- regsiri ntrziate greite
H- Testul Kruskal-Wallis, U- Testul Mann-Whitney
p<0,05, p<0,01, p<0,001

27

Cristina Popescu, Ctlina Tudose, Anca Niculi: Adaptarea Romneasca A Probei De Memorie Episodic Cu Coduri
Semantice Ri-48

Proba de memorie verbal cu coduri

semantice
EIMC
EITC
EITCa EITCb

Variabila

%
Concord
an
<34
89,1%
87%
88,5%
ECIM
<19
98,4%
69,6%
90,8%
EINT
<0,6
93,89% 65,2%
80,5%
-EINTa
93,8%
30,4%
81,7%
- EINTb <0,6
EIM-C-regsiri imediate corecte, EIT-C- regsiri
ntrziate corecte , EITa- regsire ntrziat, subscorul
a, EITb regsire ntrziat, subscorul b

28

Valoarea
prag

Sensibi
litate

Specifi
citate

Proba
de
nvare
verbal Rey:
evocare 0,615*
0,707* 0,601*
imediatscor global l
evocare 0,573*
0,690* 0,589*
ntrziat
0,472*
0,517* 0,490*
recunoatere
ntrziat
R-ACE-R,
0,586*
0,677* 0,592*
subscorul de
memorie
* p<0,001, EIMC- Evocare imediat, EITCntrziat,
EITCa Evocare ntrziat, subscorul a,
EITCb Evocare ntrziat, subscorul b

0,503*

0,446*
0,267*

0,435*

Evocare

ORIGINAL ARTICLES

PATHOLOGICAL ATTACHMENT:
ETIOPATHOGENIC FACTOR IN CHILD
PSYCHOPATOLOGY
Elisabeta Raco-Szabo1, Andrea Glicz-Nagy 2, Alina Luca 2
Abstract:
Introduction: In the child's life occur traumatizing events
that can change its behavior, transitory or lasting, and its
mental functioning, especially if the child is younger. The
child's mental vulnerability is its ability or inability to
withstand environmental constraints, its ability to
anticipate events and to alter the course or inability to
influence them. Mother-child separation remains a
traumatic event, being particularly strong in children from
5 months to 3 years. The child develops an anguished
attachment reaction described by Bowlby, whose evolution
and severity depends on the age of the child at the time of
separation and the duration of being apart.
Material and methods: 47 children were evaluated, with
ages between 5.10 and 17.8 years, they were hospitalized
in Pediatric Clinic of Neurology and Psychiatry in Tg.Mures, in 2013. They were examined clinically and
psychology-cally, they were applied different specific
scales and questionnaires: STAI-C, MASC, scared-R, CAT,
family drawing. The clinical diagnosis was established by
the DSM IV-TR ICD-10.
Results: Separation of mother and child is a traumatic
event that modifies child behavior more so how it is
smaller.
Conclusions: Absence of the mother, mental illness of the
biological parents, early institutiona-lization, physical or
emotional neglect, physical abuse, poor socio-economic
situation, the tempe-rament traits of the child constitutes
an etiopathogenic factor determining: cognitive and
affective disorders, psychosomatic manifestations,
emotional and behavioral disorders, adaptation disorders,
emphasized personality traits.
Key words: traumatizing events, mental vulnerability,
mother-child separation.

IINTRODUCTION
In the child's psychopatology, different life events may
represent risk factors for psychic diseases. Risk factors
are all the existential conditions of the child or of the
environment, that represent a risk of mental morbidity
superior to the one noticed in the general population. In the
child these risk factors may be: prematurity, neonatal
sufferance, twins, early separations, a chronic somatic
disease.
In the child's family these risk factors may be: parental
separation, chronic disagreement in the family,
alcoholism, chronic disease of a parent, incomplete couple
(single mother), death of one parent.

In society there are also a series of risk factors, such as:

migrant situation, social and economic misery, low level
of education (11).
Psychic vulnerability emphasizes the manifested or
dormant sensibilities and weaknesses, immediate or
postponed ones, and may be understood as an inability of
the child to resist to the constraints of the environment.
This may be the result of the nursling's perception and
later of the child, of his possibility to anticipate the events
and to change their course through its own competence of
active adjustment to the environment (1).
Affective deprivation produces variable effects
depending on its nature (insufficiency, distortion,
discontinuity) but also on its duration, child's age and the

University of Medicine and Pharmacy Tg.-Mure, Chief Physician, Senior Lecturer, Pediatric Psychiatry.
Clinic of Pediatric Neurology and Psychiatry Tg.-Mures: resident physician Pediatric Psychiatry.
Received October 20, 2014, Revised November 24, 2014, Accepted December 19, 2014
2

31

Elisabeta Raco-szabo, Andrea Glicz-nagy , Alina Luca: Pathological Attachment: Etiopathogenic Factor In Child
Psychopatology
mothering quality that preceded it.
The institutions that take care of nurslings have become
aware of the dangers of affective mothering, making
efforts to limit the number of persons who come in contact
with the infant.
The need of attachment is a biological need, innate and
destined for survival, constituting the premise of normal
subsequent emotional development. The biological
mother represents the primordial figure of attachment,
the primordial matrix, the reassuring niche (6).
Attachment behaviors, behaviors maintaining closeness
are: visual contact, smiling, watching, verbal
communication, taking in one's arms and cradling the
infant (3, 10).
Maternal nursing and commitment in this process
represent the early contact between infant and mother,
essential in the formation of attachment. Maternal
deprivation is the lack of positive mother-infant
interaction, due to a multitude of causes such as:
institutionalized infant, extended hospitalization, mother
with physical or psychic disorders, poverty, lack of
education, alcoholism, aggressiveness etc. Amidst the
neglectful families there may be cases of intrafamily
hospitalism (1, 8). These children present a range of
diffuse symptomatic manifestations, noticed typically in
nurslings of 5-6 months old, then in the child of 2-3 years
old. In these children, it can be noted: psycho-somatic
disorders and intercurrent infections: otitis, rhinopharyngitis, vomiting, failure to thrive; some children
suck their thumb with an absent, detached air, for a long
time; they do not interact with the adult; psychic and
language development is almost always retarded,
especially language development, and the playing is poor
(7, 8).
Mother-infant separation is a frequently encountered
event. Bowlby, 1969 (2, 3) has described 3 stages of
separation reaction: protest stage, despair stage,
detachment stage (2 ,3).
This separation reaction is especially intense in the infant
of 5 months old to 3 years old. Repeated separations are
very harmful, the child developing an extreme sensibility
and a permanent anguish, translated through an excessive
dependence of his environment, described by Bowlby as
anguished attachment reaction (3, 11). The ethiological
factors involved are: psychic disorders of the biological
parent (depression, psychosis) making the parent
incapable of an appropriate nursing, age (very young or
old parent), poor social and economic situation
(physically neglected child, without clothing and
appropriate food, insanitary dwelling, physical abuse
etc.), frequent change and replacement of the caregiver,
institutionalized child, temperamental traits of the child
(too quiet child, insufferable child, etc.) (8, 9).
If separation is extended it is noticed: a frequent stopping
of the affective and cognitive development; somatic
disorders: decrease of immunity, falling ill frequently;
psycho-somatic disorders: anorexia, nocturnal enuresis,
sleep disorders; depressive symptoms; in an older child
there are noticed school adjustment difficulties, learning
disorders, behavior disorders (11).
The evolution depends on the age at which the separation
took place and its duration (1). When affective deprivation
is severe and extended, if onsets in the first year of life and
persists for three years, it has very severe effects, which
32

seem irreversible, both on the cognitive processes

development of the child and on its personality
development.
If affective separation and deprivation begin in the 2nd year
of life, the effects on the personality development are
severe, but cognitive impairment is completely reversible.
Certain psychic alterations of the child are more severe
and less reversible: verbal impairment, abstraction
function and ability to form profound and durable
interpersonal attachments.
The children's response to a long separation from the
attachment figure is manifested initially by protest,
despair, subsequently by detachment, and reintroduction
of the attachment figure may stir up indifference, even
hostility (4, 11).
In neglected or maltreated children appear deviant forms
of attachment, presenting symptoms corresponding to the
2 clinical forms: inhibited and disinhibited.
In the inhibited form appear a series of somatic and
psychic symptoms. The somatic symptoms are: decreased resistance to infections, subnutrition, nanism,
retardation in psychomotor development.
The psychic symptoms encountered may be: inhibition,
indifference, absence or diminished interaction capacity,
hyper-vigilance, retardation in psychic development but
mostly of the language (5).
In the disinhibited form the somatic symptoms
encountered are: decrease of immunity and resistance to
infections.
At the same time appear also a series of psychic
manifestations such as: aggressiveness, emotional
instability, superficial friendship relationships, aggressive
behavior, hyperactivity, indifference towards the
caregiver, undiscriminated sociability (7, 8).
Children with a sure attachment have better adjustment
abilities, and they create coping strategies in difficult
situations (7, 8).
MATERIAL AND METHOD
There have been monitored during the year 2013, 47
children admitted to the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures with different psychiatric clinical
diagnoses taking into account they are based on the
attachment disorder. The patients have been somatically,
psychically and psychologically examined, there were
performed various paraclinical laboratory investigations,
and applied various tests, scales and questionnaires
(Raven, BDI, BECK, CAT, TAT, family drawing, STAI-C,
MASC, SCARED-R, etc.) both to the child and parents. In
anamnesis we monitored data related to the social and
family factors, heredo-collateral factors related to the
psychiatric area, the somatic, psychic and language
development, sex and origin of environment. The data
obtained has been represented graphically, the results have
been interpreted and certain conclusions have been drawn,
relating permanently to the specialized literature data.
RESULTS
In the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures, in 2013, have been admitted 848
children, among which 47 have been diagnosed with
Attachment Disorder according to the DSM IV-TR and
ICD 10 criteria, representing 6% of the total admissions
(Figure 1).

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

Figure 1. Admissions in the Clinic of Pediatric Neurology

and Psychiatry Tg.-Mures, in 2013

The reasons for admission were various,

consisting in: verbal impulsiveness: 22 patients (46,8%);
hetero-aggressiveness: 27 patients (57,4%); selfaggressiveness: 5 patients (10,6%); sad disposition: 17
patients (36%); sleep disorders (insomnia, frequent
awakenings, morning fatigue, nightmares): 10 patients
(21%); decrease in school results: 18 patients (38%);
school absenteeism: 8 patients (16%); hyperactivity,
instability: 11 patients (22%); behavior disorders with
vagrancy, theft, lie, alcohol consumption, smoking: 17
patients (36%); somatoform manifestations: cephalalgia,
thirst for air, precordial pains, abdominal pains: 13
patients (26%); retardation of psychic development: 3
patients (6%); language development disorders: 5 patients
(10,6%); statural and ponderal hypotrophy: 8 patients
(16%) (Figure 5).

The patients have been somatically, psychically

and psychologically examined, applying also different
scales and questionnaires both to children and mothers.
They presented various clinical manifestations:
behavioral, affective, hyperkinetic, autolytic attempts,
disharmonic personality development, etc.
The age of patients was between 5,10 and 17,8 years old.
Among which 12 patients (25,4%) were male and 35 (74,6
%) female (Figure 2).

Figure 5. The reasons for admission of monitored children

admitted in the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures, in 2013

Figure 3. The environment of monitored children

admitted in the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures, in 2013

The patients have been psychologically assessed

by Raven test, in order to establish the cognitive
development level. Thus it has been outlined: normal
intellect in 38 patients (80%); mild mental retardation in 2
patients (4%); liminality in 7 patients (15%) (Figure 6).

Heredo-collateral antecedents concerning the

psychic pathology of the biological parents as a prone
factor, were emphasized in 10 patients (21, 2%).
Thus: depression in biological parents, at 4 children
(8,5%); schizophrenia: in 1 case (2,1%); personality
disorders in the families of 5 children (10,6%) (Figure 4).

Figure 6. Cognitive development level of monitored

children admitted in the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures, in 2013

Figure 4. Heredo-collateral antecedents of monitored

children admitted in the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures, in 2013

Among the social and family factors with

importance in the etiology of attachment disorder, there
were pointed out the following:
death of a parent: in 6 children (8.57%); child
abandonment with placement in family type house or
maternal assistant: in 18 cases (25.71%); extreme poverty
with physical neglect: in 11 cases (15.71%); intra-family
conflicts: in 13 cases (18.57%); affective neglect in
family: in 7 cases (10%); alcohol consumption in family
33

Elisabeta Raco-szabo, Andrea Glicz-nagy , Alina Luca: Pathological Attachment: Etiopathogenic Factor In Child
Psychopatology
and physical abuse of the child: 15 cases (21.43%) (Figure
7).

Figure 7. Family factors with importance in the etiology of

attachment disorder for admission of monitored children
admitted in the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures, in 2013
For the diagnosis, in addition to the psychic
examination there were applied different scales such as:
STAI-C, MASC, CDI, BECK, projective tests (CAT,
TAT), SCARED-R, and family drawing also. At the same
time questionnaires were also used for parents. They have
pointed out modifications based on which we could
diagnose: ADHD: 5 cases (10,6%); anxious-depressive
disorder: 8 cases (16%); socialized behavior disorder: 17
cases (36%); autolytic attempts: 7 cases (15%);
disharmonic personality development: 10 cases (21%)
(Figure 8).

Disharmonic personality development has been

outlined in case of 10 patients (21%); they have presented
either borderline type elements (4 patients: 8,5%), or
antisocial type (2 patients: 4%), or anxious-avoidant type
(4 patients: 8,5%) (Figure 10).

Figure 10. Disharmonic personality development at

monitored children admitted in the Clinic of Pediatric
Neurology and Psychiatry Tg.-Mures, in 2013
In case of a patient with Attachment Disorder and
repeated autolytic attempts, with disharmonic personality
development of borderline type, the family drawing has
been suggestive, not representing himself in the family
drawing (only the father, mother and brother) (Figure 11).

Figure 11. Case of a patient with Attachment Disorder and

repeated autolytic attempts, with disharmonic personality
development of borderline type
Figure 8. Diagnoses of monitored children admitted in the
Clinic of Pediatric Neurology and Psychiatry Tg.-Mures,
in 2013
Autolytic attempts have been present in 7
patients (15%), they consisted in: voluntary medicine
ingestion in 4 cases (8,5%); defenestration: 1 case (2%);
veinsection in 2 cases (4%) (Figure 9).

Figure 9. Autolytic attempts for monitored children

admitted in the Clinic of Pediatric Neurology and
Psychiatry Tg.-Mures, in 2013
34

The specialized treatment of the monitored

patients has consisted in anxiolytic medication
(Alprazolam), antidepressants with ISSR (Sertraline),
mood stabilizers (Carbamazepine, Valproic Acidum).
Furthermore, it has been performed a psychological
intervention consisting in family counseling, individual
psychotherapy of cognitive-behavioral type. In children
with retardation in psychic or language development there
has been performed stimulation, in addition we used
ludotherapy and drawing therapy.
In cases in which affective deprivation and neglect were
emphasized, it has been disposed social and family
reinsertion to maternal assistant, family type house or
change of placement. At the same time it has been
recommended psychiatric treatment for parents with
depression or psychoses and it has been disposed the
removal of the child from the natural family and his
nursing by grandparents on condition that the family
environment stays stable.
DISCUSSIONS
The specialized literature reminds of the fact that
certain events in the child's life may be risk factors for
psychic diseases and namely: prematurity, early

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

separations, chronic somatic disease, conflicts in family,
alcoholism of biological parent, atypical families
(incomplete couple: single mother), poor social and
economic situation, immigrant status, low level of
education (5, 11). These factors have been emphasized
also in children from our trial and namely: child
abandonment with placement in family type house (18
cases), poor social and economic situation (11 cases),
conflicts in family (13 cases), alcohol consumption and
physical abuse of the child (15 cases), affective neglect of
the child by biological parent ( 7 cases).
For etiological factor in the attachment disorder there are
mentioned in the specialized literature the psychic
disorders in biological parents, the child's
institutionalization with frequent change of the caregiver,
biological parent's age, either too young or too old, etc. (1,
4). In children who are in our trial, in 10 cases (21,28%) it
has been emphasized the existence of the psychic disease
in the biological parent and namely: depression,
schizophrenia, various personality disorders.
Attachment behaviors mentioned in the specialized
literature are: visual contact, smiling, infant cradling,
verbal communication with the infant (3), their absence
determining the apparition of the anguished attachment
reaction, the child presenting either frequent
intercurrences or somatic development retardation, or
psychic retardation or language development retardation,
or aggressive behavior, hyperactivity, carelessness
towards the family, undiscriminated socialization etc.,
which it has been noticed also in the patients included in
our trial. The psychic functions the most severely affected
in the children in our trial have been: verbal function,
abstracting function, the ability to form profound and
durable attachments. Affective deprivations produce
variable effects on the child's development depending on
their nature, duration, child's age and mothering quality,
consisting in the retardation of the cognitive development,
as well as producing effects on the child's personality.
CONCLUSIONS

physical neglect, physical abuse, poor social and

economic conditions, family conflicts etc.) constitute a
etiopathogenic factor (RUTTER).
Reactive attachment disorder is manifested by: cognitive
disorders, psycho-somatic manifestations, emotional and
behavioral disorders, adjustment disorders, pronounced
personality disorders.
Mother-infant separation is a psycho-traumatic event
which changes the child's behavior, all the more so as the
child is younger, in the first year of life having irreversible
effects on the cognitive development.
There are severely affected: the verbal function, the
abstracting function, the ability to form profound and
durable interpersonal attachments.
BIBLIOGRAPHY
1.Ainsworth M.D.S. The development of infant mother attachment.
Chicago Review of child development research 1979;3.
2.Bowlby J. Attachement et perte: la separation ongoisse et colere.
(Attachment and loss: separation, anguish and rage). Paris: PUF, 1978.
3.Bowlby J. Attachment and loss, Vol 1 Attachment. New York: Basic
Books, 1982.
4.Cicchetti D, Cummings E.M, Greenberg M.T. An Organizational
perspective on attachment beyond infancy. In: Greenberg M.T, Cichetti
D, Cummings E.M. (eds). Attachment in the preschool years. Chicago:
Chicago University Press, 1990.
5.Dobrescu I. Manual de psihiatria copilului si adolescentului, (Child
and Adolescent Psychiatry Manual). Bucureti : Ed. Infomedica, 2010,
229-239.
6.Izard C.E. et al. Emotional determinants of infant-mother attachment.
Child development 1991, 62.
7.Kaufman I. Depressive disorders in maltreated children. J. Am. Acad.
Child Adolesc. Psyhiatry 1991;30(2): 257-259.
8.
Martin A., Volkmar F. Lewis's Child and Adolescent Psychiatry.
Philadelphia: Lippincott Williams and Wilkins, Fourth Edition, 2007,
711-717.
9.Marcelli D. Tratat de psihopatologia copilului. (Child
Psychopathology Treatise). Ed. Fundaiei Generaia, 2006, 446-474.
10.Mircea T. Tratat de psihopatologie a dezvoltarii copilului si
adolescentului. (Psychopathology Treatise of Child and Adolescent
Development). Timisoara: Editura ArtPress, 2006, 83-87, 337-355.
10. Rutter M, Bishop D, Pine D, Taylor E. Rutter's Child and Adolescent
Psychiatry, Fifth Edition. Blackwell Publishing, 2009, 906-913.

***

Affective deprivations (mother's absence, psychic

diseases of the biological parent incapable of an
appropriate nursing, early institutionalization, affective or

35

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Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

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Instructions for authors

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38

Romanian Journal of Psychiatry, vol. XVII, No.1, 2015

Address to send the manuscripts is:

REVISTA ROMN DE PSIHIATRIE
ASOCIAIA ROMN DE PSIHIATRIE I PSIHOTERAPIE
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WPA 2015
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ROMANIAN JOURNAL
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CONTENTS
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CO-EDITORS:

SPECIAL ARTICLES
& Cardiovascular Comorbidity Associated with Schizophrenia
Spectrum Disorders
Veronica Ruanu, Roxana M Stoean, Mirela Manea, Bogdan E Patrichi,
Alina Frunz

& Adult ADHD A New Entity in Psychiatry (DSM V)

Laura Aelenei

Diagnosing Personality Disorders: A Modern View

Istvn Zs Szsz, Adrian I Horvath, Tudor Niretean, Anna M Tth

& Animal Assisted Therapy- Benefits for Patients

Ramona L Punescu, Alina S Rusu, Anca Zgrian, Veronica ut,
George Mooia, Ioana V Micluia

10

ORIGINAL ARTICLES
& Personality Disorders and Psychotic Disorders Co-Morbidity
in Forensic Inpatients
Monica D Moescu, Alina V Ungureanu, Magdalena Dragu,
Gabriela Costea
& Romanian Adaptation of Episodic Memory Test with
Semantic Codes RI-48
Cristina Popescu, Ctlina Tudose, Anca Niculi
&

Pathological Attachment: Etiopathogenic Factor in

Child Psychopatology
Elisabeta Raco-Szabo, Andrea Glicz-Nagy, Alina Luca

INSTRUCTIONS FOR AUTHORS

14

22

31

36

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REVIEW ARTICLES
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Dan PRELIPCEANU
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Medical Sciences, Iai)
Michael DAVIDSON (Professor, Sackler
School of Medicine Tel Aviv Univ.,
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New York)
Virgil ENTESCU (Member of the Romanian
Academy of Medical Sciences, Satu
Mare)
Ioana MICLUIA (UMF Cluj-Napoca)
erban IONESCU (Paris VIII Universiy, TroisRivieres University, Quebec)
Mircea LZRESCU (Honorary Member of the
Romanian Academy
of Medical Sciences, Timioara)
Juan E. MEZZICH (Professor of Psychiatry
and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
Sinai School of Medicine, New York
University)
Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Department of Psychiatry,
University of Maryland School of
Medicine, Baltimore)
Sorin RIGA (senior researcher)
Dan RUJESCU (Head of Psychiatric Genomics
and Neurobiology
and of Division of Molecular and
Clinical Neurobiology,
Department of Psychiatry, LudwigMaximilians-University, Munchen)
Eliot SOREL (George Washington University,
Washington DC)
Maria GRIGOROIU-ERBNESCU
(senior researcher)
Tudor UDRITOIU (UMF Craiova)

www.romjpsychiat.ro