COMITET DE REDACŢIE

Redactor şef: Dan PRELIPCEANU

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

REVISTA
Marieta GABOŞ GRECU
Maria LADEA
Cristinel ŞTEFĂNESCU
Cătălina TUDOSE

Secretar de redacţie: Valentin MATEI

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

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

ARPP ROMANIAN JOURNAL OF PSYCHIATRY

ASOCIAŢIA ROMÂNĂ Vol XIX Nr. 2 June 2017

DE PSIHIATRIE ŞI PSIHOTERAPIE
QUARTERLY

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

CUPRINS

EDITORIAL

& Sindromul burnout 33

Dan Prelipceanu, Raluca Barbu

ARTICOLE SPECIALE

& ABB – Criminalul norvegian. Psihoză versus psihopatie - analiză medico-legală psihiatrică 36
Gabriela Costea

ARTICOLE DE SINTEZĂ

& Aspecte genetice ale alcoolismului 48

Maria Bonea, Ioana V. Micluţia
& Factori psihosociali care influențeaza sindromul Asperger 52
Mihai Gabriel Alin Șuiu Apostol, Oana Boantă, Mihnea Manea, Iuliana Dobrescu

ARTICOLE ORIGINALE

& Nivele ridicate de fibrinogen, un posibil indicator al dezechilibrului psihic și al depresiei 55

Traian Purnichi, Gabriela Puiu, Ileana Marinescu, Mihail C. Pîrlog, George Paraschiv, Silvia Ristea,
Ruxandra Banu, Ioana G. Pavel, Mihai Bran, Lavinia Duică, Ruxandra Grigoraș, Valentin P. Matei
& Factori asociați cu aderența la tratament la pacienții cu schizofrenie 59
Ana M. Romoșan, Felicia Romoșan, Liana Dehelean, Mihaela A. Simu, Virgil R. Enătescu,
Cristina A. Bredicean, Ion Papavă, Iris Druț, Mihaela O. Manea, Ioana Riviș, Simona D. Rădulescu,
Radu Ș. Romoșan
& Evaluarea sindromului metabolic și calitatea vieții într-un eșantion de pacienți în tratament cu
olanzapină depot 65
Ana-Anca Talașman, Mihaela Nae, Alexandra Dolfi,Irina Luca, Mihai V Zamfir
& Incidența delirium-ului postoperator și a stresului oxidativ în chirurgia laparoscopică 69
Andreea D. Stanculescu, Dominic G. Iliescu, Octavian Dragoescu, Andrei Drocas, Mihail C. Pirlog,
Stefania Tudorache, Florea Purcaru, Traian Purnichi, Nicoleta A. Dragoescu

CAZ CLINIC

& Episod psihotic acut la un pacient cu encefalopatie cauzata de infecția cu HIV 74

Ana-Anca Talasman, Alexandra Dolfi, Mihaela Nae

INSTRUCŢIUNI PENTRU AUTORI 77

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

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

Revista Română de Psihiatrie este editată de Asociaţia Română de Psihiatrie şi Psihoterapie

şi Asociaţia Medicală Română
EDITORIAL
BURNOUT SYNDROME
Dan Prelipceanu1, Raluca Barbu2
Online dictionaries provide a suggestive
translation for the burnout concept: „The tubes burned out
easily and had to be constantly replaced...”.This is the
sequence of events that leads to the syndrome: the
depletion of one's own intellectual energy, usually directly
tied to the profession one has, presumably exerted with
great passion and dedication, after a long lasting effort.
The most accurate definition, including the
eventual prophylactic actions to be taken, is based on the
context in which this syndrome manifests: the surpassing
of one's resistance to professional effort and of one's
capability to recuperate (1,17). Its manifestation,
perceived by others and by the affected individual consists
of behaviors and feelings, more or less subjective, noticed
by the individual and/or those around him/her. The most
common symptoms overlap those found in various types
of depression: fatigue, insomnia, difficulty concentrating,
irritability, depressed mood, lack of pleasure and
motivation for daily activities concerning - surprisingly –
those linked to professional activity. Other symptoms are
included in the psychosomatic category: headaches,
lumbago, gastrointestinal problems, breathing difficulties,
loss of appetite, various cenesthetic complaints.
If we use the word symptoms we must include our
description in the biological model, which is not necessary
the case here. Official psychiatric classifications do not
recognize burnout as a form of depression. International
Classification of Diseases (ICD 10, 1992) (2) includes this
syndrome in the last chapter (amongst “Factors
influencing health status and contact with health services”
codes Z00-Z99, in “Problems related to life management
difficulty” code Z73.0 together with other “problems”,
such as “Accentuation of personality traits” including type
A behavior pattern, “Lack of relaxation and leisure”, “
Stress, not elsewhere classified”, “Inadequate social skills,
not elsewhere classified”, “Social role conflict, not
elsewhere classified”, ranging from Z73.1 to Z73.5), all of
which do not refer to nosological entities, but to
particularities varying with context and eventually with
the individual's psycho-social vulnerability.
We can thus define burnout as a cumulation of
psychological symptoms, more or less interchangeable
with the psychiatric equivalents, already indexed among
the diagnostic criteria of some psychiatric disorders
(exhaustion depression, stress disorders etc.) (3). It is true
that, given time, these psychological symptoms and
disfunctions can translate to actual depressive symptoms.
Because burnout is, in fact, a surpassed work-related state,
it is wise to be aware that the onset of the symptoms might
show a change in the individual's professional life. This
means that the professional act, which one performs with a
1
MD, PhD, Prof. of Psychiatry, IX Ward Prof. Dr. Al. Obregia Academic Psychiatric Hosp., Bucharest, prelipceanudan@yahoo.com
2
MD,Psychiatry second year resident, IX Ward Prof. Dr. Al. Obregia Academic Psychiatric Hosp., Bucharest
This paper is based on: Dan Prelipceanu, Burn - out - a price paid to scientific creativity, published in Jurmed.Jurnalul de Sanatate,2016 issue.
Received January 7, 2017, Revised February 26, 2017, Accepted March 8, 2017.
degree of satisfaction, is disrupted by something
unpleasant or disappointing that later becomes stressful.
Oftentimes, work-related stress can be induced by an
unsatisfied expectation that later becomes frustration. The
intensity of this frustration depends on one's narcissism
regarding one's value in relation to professional success.
This psychological selfishness, as it is named by some
psychologists and philosophers, may be the starting point
of workaholism as a gratification for a creative but
hedonistic individual who sees professional success as the
payoff for the effort invested in it, but also overlaps with
the pleasure of feeling it subjectively, contemplating the
success from the height of one's vanity. This is why using
the term burnout is often excessive: it should be limited
only to those individuals who manifest these symptoms in
the context of an intense professional activity (some call it
work-related stress) with high stakes (researchers, top
positions that require a lot of personal, emotional and
intellectual involvement). In some professions the risk of
burnout is a priori accepted, and thus these professionals
benefit from financial gratification or prolonged
recreation leaves (psychiatrists have salary increments
and prolonged recreation leave, the so called “dangerous
conditions bonuses”, and so do coroners, pilots, train
operators etc.).
Due to burnout, the individual experiences a decrease in
the capability to cope usual work-related requirements
and situations, which he/she easily and pleasurably
resolved before, followed by an increasing lack of interest
for these activities, despondency and loss of motivation to
further pursue them. Finally, the individual begins to
question whether one's professional pursue, so personally
and intellectually invested upon, has any meaning at all.
Trying to quantify the subjective disturbances burnout
casts upon the individual, authors write about
“exhaustion, cynicism, lack of personal accomplishment”
as defining dimensions from a social psychology point of
view, in contrast to the “energy, involvement, efficiency”
prior to the onset of burnout (4).
Recent arguments stand for the extension and
equalization of the burnout concept to chronic stress that
can appear in various circumstances, not only work-
related (5). These authors believe that “unresolved stress”
cannot be taken in consideration only when it comes to
professional activity and thus, this disorder should be
considered as a multidimensional one, with positive
consequences in the research of chronic stress in general
and especially regarding prevention. Many branches of
medicine and psycho-sociology are, indeed, connected to
this syndrome even if it isn't a nosological entity in the
official classification, which in change contains many
33
Dan Prelipceanu, Raluca Barbu: Burnout Syndrome: A Marginal Psychiatry Disorder?
formulations of clinical symptoms as consequences of
chronic stress, be it work-related stress or any other form.
We can, therefore, deduce that, what we often call burnout
can, in some situations, be reinterpreted as chronic
stress/acute stress disorder/posttraumatic stress
disorder/depressive reaction to stress or other concepts
from the official or unofficial medical or psychiatric
jargon.
However one may call this aggregate of
psychological symptoms, which, in time, becomes (or
not) characteristic of psychiatric/psychosomatic
disorders, it is often accompanied by biological findings
(an increase in serum level of stress hormones, linked to
major clinical consequences), negative functional
outcome (a decrease in working efficiency), somatic
comorbidities, some with severe or even fatal
consequences (cardiovascular disease, myocardial
infarction), psychiatric comorbidities or complications
(depression, suicide, transient cognitive impairment),
worsening of some psychosomatic disorders (respiratory,
cardiovascular, immune, dermatological issues). New
research is showing just how devastating this kind of
occupational stress can be to the brain, causing changes
both in the structure and function of this organ. The
emotional and cognitive turmoil of burnout leaves a
signature mark in specific brain areas associated with
cognition, memory, attention and emotional response,
MRI results showing a reduction in gray matter in the
medial prefrontal cortex, hipoccampus, caudate and
putamen and an enlargement of the amygdala (6). Burnout
can alter neural circuits, R-fMRI showing weaker
connections between the amygdala and areas linked to
emotional distress (anterior cingulate cortex) and
executive function (medial prefrontal cortex) (7). Data
from animal experiments show that stress causes an
enhanced release of glutamate, neurotoxicity affecting
regions such as the medial prefrontral cortex, the anterior
cingulate, and the basal ganglia. These results are
consistent with neuroimaging findings in subjects who
have experienced severe early-life trauma. In addition to
dysregulation in brain function, emerging evidence
suggests that burnout also leads to stress-related changes
within the regulation of the body's neuroendocrine
system, especially the hypothalamic–pituitary–adrenal
axis. Chronically elevated cortisol levels eventually lead
to the down-regulation of this stress hormone to
abnormally low levels, a state called hypocortisolism.
Hypocortisolism induces low-grade inflammation
throughout the body, arteries responding with a buildup in
plaque over time, leading to cardiovascular disease (8).
Like all psychiatric/psychosomatic disorders, the
importance of stress depends on the subjective
significance of the traumatizing/stressful event every
individual perceives, according to the classical model
given by German psychiatrists of the mid-20th century (9)
of “key moment”/”formative experience”
(Schlusserlebnis). Just like a key (the acute or chronic
stress event) fits to the subjective “lock” (the specific
vulnerability given by the personal significance of the
stressor for the individual), the stressor becomes more
severe if it “fits” to the area of maximal personal
motivation of the individual. Kurt Schneider underlined
the importance of immediate subjective context
(Hintergrund) and that of the background affect and mood
34
(Untergrund) and the role these play in the moment facing
the stressor (10). These authors have plastically described
this mechanism as an “Achilles heel” that is responsible
for the vulnerability permitting the event (or a sum of
events) to create the subjective experience of burnout,
reactive depression, exhaustion depression etc.
We find this mechanism in the list of possible work-related
circumstances and situations, as a premonition of burnout
onset, as the term was first coined by Herbert
F r e u d e n b e rg e r ( 1 9 7 4 ) ( 11 ) : p r o f e s s i o n a l
dissatisfaction/even that of personal life, which appears as
a daily useless waste of energy, the onset of fatigability
then exhaustion, perceiving all daily activities as
pointless, onerous, as if slowing down one's thinking, the
activity lacks drive, all of this being perceived by the
individual and those around him/her, including superiors.
This setting takes shape when work seems to lose its
motivation, when it is not longer recognized by those
significant for the individual, when there is a lack of
results or when positive results are assumed by others etc.
Therefore, the person afflicted by burnout goes trough
feelings of disengagement, hopelessness, self
depreciation, detachment and abandonment from others.
It is useful for those who are active and
competitive to know the alternative to burnout so they can
take precautions: avoiding chaotic activity under the self
imposed pressure of being performant at any cost,
avoiding unrealistic expectations, avoiding losing control
over the rhythm of one's work, avoiding the workaholic
defective lifestyle which involves the lack of necessary
periods of relaxation, rest and sufficient recovering sleep,
avoiding perfectionism and learning how to delegate
tasks. In type A personality (12), characterized by
hipercompetitivity-ostility, ambition, eagerness to
complete the set professional objective (by means of total
professional implications which leads to work-
dependence known as workaholism), all of these
behaviors developing under the pressure of time, the
situation must be recognized by others or by oneself in
order to take the appropriate measures to adapt it to reality:
the potential pessimistic view of the world must be
replaced by a positive, constructive one, the social support
system must be used in order to socialize when one feels
overwhelmed, so does the “trusted-confident” system to
depressurize moments of decision over one's own choices.
Once installed, burnout can be counteracted with
coping and self-care strategies. The Resilience
Development Model defines resiliency as a cyclical
process of uncovering, using, and developing the innate
self, motivating life force, human spirit, or strength that
lies within (13). Yoder suggested strategies which include
taking vacations, changing assignments, developing
supports, developing personal awareness, having rituals,
and changing jobs. Other self-care strategies included
maintaining adequate sleep patterns, good nutrition,
regular exercise, and relaxation (14). Developing
techniques such as meditation, mindfulness, deep
breathing, self-reflection, and humor and massage could
also be therapeutic (15). As for health care professionals it
is important to be able to set boundaries to maintain
personal/professional balance (16, 17).

References
1.Attwel KC, Physician and medical student mental health. In: Sadock
BJ, Sadock VA, Ruiz P (Eds). Kaplan&Sadock's Comprehensive
Textbook of Psychiatry. Philadelphia, PA: Wolter Kluwer Lippincott
Williams&Wilkins, 2009, 2703-2716.
2.WHO (1992), ICD – 10. Clasificarea tulburărilor mentale și de
comportament. Simptomatologie și diagnostic clinic. Bucureşti: All,
1998, 365-370.
3.Wilson JL (2015, March). Burnout questionnaire (adapted from
"Symptoms of Burnout" (Freudenberger, H. Burnout. P18; Bantum, NY,
NY; 1981)). Retrieved from https://adrenalfatigue.org/burnout-
questionnaire/.
4. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory.
Manual(3rd ed.). Palo Alto, CA: Consulting Psychologists Press, 1996.
5.Bianchi R, Truchot D, Laurent E, Brisson R, Schonfeld IS. Is burnout
solely job-related? A critical comment. Scandinavian Journal of
Psychology, 2014; 55(4):357-361.
6.Golkar A, Johansson E, Kasahara M, Osika W, Perski A, Savic I. The
influence of work-related chronic stress on the regulation of emotion and
on functional connectivity in the brain. 2014;PLOS ONE 9: e104550.
7.Liston C, McEwen BS, Casey BJ. Psychosocial stress reversibly
disrupts prefrontal processing and attentional control. Proceedings of the
National Academy of Sciences, 2009;106:912–917.
8.Oosterholt BG, Maes JH, Van der Linden D, Verbraak MJ, Kompier
MA. Burnout and cortisol: Evidence for a lower cortisol awakening
response in both clinical and nonclinical burnout. Journal of
Psychosomatic Research, 2015;78:445–451.
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
9.Kretschmer E. Der Senzitive Beziehungswahn (4th ed.). Berlin:
Springer, 1966.
10.Schneider K. Klinische Psychopathologie (7th ed.). Stuttgart: Georg
Thieme Verlag KG, 1947.
11. Freudenberger HJ. Staff Burn-Out. Journal of Social Issues,
1974;30:159–165.
12. Friedman M, Rosenman R. Type A behavior and your heart. New
York: Knopf, 1974.
13. Grafton E, Gillespie B, Henderson S. Resilience: the power within.
Oncol Nurs Forum. 2010;37(6):698–705.
14. Yoder E. Compassion fatigue in nurses. Appl Nurs Res.
2010;23(4):191–197.
15. Swetz K, Harrington S, Matsuyama R, Shanafelt T, Lyckholm L.
Strategies for avoiding burnout in hospice and palliative medicine: peer
advice for physicians on achieving longevity and fulfillment. J Palliat
Med. 2009;12(9):773–777.
16. Showalter S. Compassion fatigue: what is it? Why does it matter?
Recognizing the symptoms, acknowledging the impact, developing the
tools to prevent compassion fatigue, and strengthen the professional
already suffering from the effects. Am J Hosp Palliat Med.
2010;27(4):239–242.
17. Maslach C, Leiter MP. Understanding the burnout experience: recent
research and its implications for psychiatry. World Psychiatry, 2016;
15:103-11.
***
35
SPECIAL ARTICLES
ABB – CRIMINALUL NORVEGIAN. PSIHOZĂ
VERSUS PSIHOPATIE - ANALIZĂ MEDICO-
LEGALĂ PSIHIATRICĂ
Gabriela Costea1
Rezumat:
Anders Breivik, criminalul terorist norvegian nu a reținut
atenția comunității internaționale doar prin faptele sale
abominabile ci și prin disputele științifice psihiatrice pe
care le-a generat. În acest articol sunt prezentate cele
două rapoarte de expertiză medico-legală psihiatrică
precedate de o introducere ce cuprinde tematica legată de
terorism în general și de extremismul naționalist al
criminalului. Cele două expertize medico-legale
psihiatrice reprezintă adevărate lecții de psihiatrie și mai
ales de psihiatrie medico-legală.
CUVINTE CHEIE: psihoza paranoidă, tulburare de
personalitate, terorism, omor, extremism.
INTRODUCERE
La data de 21.07.2011 întreaga planetă resimțea
undele unui șoc ce paralizase una din țările cu cel mai
ridicat nivel de trai – Norvegia; un tânăr ucisese un număr
de 70 de persoane și rănise alți 240. Povestea lui Breivik
Anders Behring continuă și în prezent. Cu același interes
cu care au fost urmărite evenimentele privind activitatea
ucigașă, comunitatea internațională a urmărit și comentat
expertizele medico-legale efectuate de către psihiatrii
norvegieni. În vederea înțelegerii aprofundate a disputelor
psihiatrice voi prezenta, succint, definiții și caracteristici
tehnico-operaționale ale unor subiecte/domenii/fenomene
”nepsihiatrice” dar tangente la sistemele de raționament
medico-legal psihiatric (în speța ”Breivik”) precum și
cadrul (comparativ european) în care se desfășoară
expertizele medico-legale psihiatrice.
1. CONFORM DICȚIONARULUI EXPLICATIV AL
LIMBII ROMÂNE (1), ”Creștinismul” reprezintă
ansamblul religiilor bazate pe ”credința în persoana și
învățăturile lui Iisus Cristos” / pe ”Vechiul și noul
testament”; ”Islamismul” / mahomedanismul este o religie
monoteistă bazată pe ”preceptele Coranului”;
”extremismul” definește o ”atitudine, doctrină a unor
curente politice care, pe baza unor opinii, idei, păreri
exagerate, unilaterale, extreme, urmăresc prin măsuri
violente sau radicale să impună programul lor”;
”naționalismul” reprezintă o ”doctrină politică bazată pe
apărarea (uneori exagerată) a drepturilor şi aspiraţiilor
naţionale”; ”extremismul nationalist” definește
ideologia/politica care urmăreşte întreţinerea izolării şi
aţâţarea neîncrederii şi urii între diferite naţionalităţi,
tendinţa de a aprecia exclusiv şi exagerat tot ceea ce
aparţine propriei naţiuni”. Terorismul reprezintă
totalitatea actelor de violenţă comise de un grup sau de o
organizaţie pentru a crea un climat de insecuritate sau
1
Medic primar psihiatru, INML ”Mina Minovici”, București
Received January 5, 2017, Revised February 21, 2017, Accepted March 15, 2017.
36
Abstract:
Anders Breivik, the norwegian terrorist offender has
captured the attention of the international community not
only for his horrific acts but also due to the psychiatric
scientific discussions created by the event. This paper
presents the two resulting files from the forensic
psychiatric expertise, with an introduction discussing
terrorism in general and the national extremism of the
offender. The two forensic psychiatric evaluations
represent solid lessons of psychiatry and forensic
psychiatry in particular.
KEY WORDS: paranoid psychosis, personality disorder,
terrorism, murder, extremism.
pentru a schimba forma de guvernământ a unui stat; se
caracterizează prin folosirea deliberată şi sistematică a
unor mijloace violente sau ameninţări de natură să
provoace teamă şi neîncredere, panică şi nesiguranţă, cu
ignorarea a oricăror norme umanitare. ”Jihadul” (2)
denumește conceptul de ”război sfânt”, al islamului, de
apărare a religiei mahomedane.
2. ”COUNTER – JIHAD” (CJM) (3,4,5,6) este o mișcare
transatlantică care militează pentru împărtășirea
ideologiei extermiste antiislamice printre europeni și
americani prin conectarea zilnică între bloguri și site-uri
Web pe ambele maluri ale Atlanticului; principalul blog
CJM a devenit vizibil în anul 2004 și principalul grup a
apărut în anul 2006, în Viena (”Gates of Viena”); mișcarea
a devenit semnificativă după 11 Septembrie 2011. În
concepția acestei mișcări, ”scena anti-jihad” ar fi
reprezentată de un scenariu în care Europa și SUA sunt
amenințate de lumea islamică (agresivă) care dorește să
preia Europa, preluare ce ar consta printr-un proces de
islamizare îndepărtarea simbolurilor creștine sau
evreiești, impunerea tradițiilor islamice și crearea de zone
nedisponibile pentru non-musulmani; în acest sens,
Europa –în declin și în plină decadență – se află în
imposibilitate de a rezista preluării de către islam (mai
puternic din punct de vedere spiritual). Discursul anti-
jihad este o mixtură între preocupările privind terorismul
inspirat de jihad și probleme politice complexe relaționate
cu imigrația în Europa, sugerându-se că amenințarea nu
este produsă de extremiștii islamici ci și de Islam ca atare,
de unde, prin extensie, toți musulmanii din Europa (o
”coloană a V-a”) ar reprezenta o amenințare pentru
populația europeană creștină, pentru identitatea și valorile
acesteia.
3. ORGANIZAȚII ȘI PARTIDE EXTREMISTE: În afară
de mișcarea ”anti-jihad”, în Europa mai sunt active multe

alte organizații și partide. În anul 1984, partidele
extremiste europene au format alianța ”Grupul dreptelor
europene” , denumit în prezent ”Grupul Europa – libertăți,
democrație”; în anul 2001 s-a constituit ”Alianța
europeană pentru libertate”, recunoscută de Parlamentul
European (7). Dintre organizațiile extremiste cea elenă,
denumită ”Zori Aurii” este responsabilă de uciderea
muzicianului antifascist Pavlos Fyassas. Extremiștii
(grupați sau nu în organizații sau partide) militează pentru
o Europă fără musulmani și imigranți, pentru antisemitism
și pentru măsuri discriminatorii împotriva țiganilor și
săracilor (8). Relativ la Anders Breivik se menționează
apartenența la ”Partidul Progresului” din Norvegia și la
”Liga Engleză de apărare” (9). Partidul Progresului este
format din indivizi proveniți din clasa de mijloc și din
rândul intelectualilor; ideologia este centrată împotriva
musulmanilor; din anul 2013, partidul a intrat la
guvernare. ”Liga Engleză pentru apărare”, apărută inițial
în mediul virtual, a devenit activă prin organizarea și
coordonarea de marșuri, campanii și de răspândire a
cunoștințelor și tacticilor de luptă extremistă; analiștii
consideră că ideologia acestei organizații a reprezentat, de
asemenea, o sursă de inspirație pentru Anders Breivik și
pentru alți teroriști.
4. ODINISMUL (10) este religia antică dedicată zeilor
panteonului norvegian. Odiniștii se referă la ei înșiși ca
urmași ai lui Asatru. Religia denumită în prezent
”Odinism” reprezintă tradiția indigenă a ramurii
germanice a popoarelor indo-europene, fiind de origine
precreștină cu caracteristici documentate din paleolitic.
Ritualul odinic (cu apel la ”Wotan”) a fost reorganizat în
anul 1972 în Anglia; au fost înființate ”comunități
odiniste” în mai multe țări (inclusiv ”nongermanice”) dar
există și grupuri de ”odiniști individuali” (mai ales în țările
scandinave). Din anul 1973, ”Odinismul / Asatru” a fost
recunoscut oficial de către guvernele Islandei,
Danemarcei și Norvegiei. Odiniștii moderni își însușesc
un cod de viață bazat pe respectarea a nouă precepte dintre
care se rețin (ca având valoare în dezvoltarea
personalității): curajul, adevărul, onoarea, fidelitatea,
disciplina, ospitalitatea, perseverența. Regulile sunt
exprimate prin exprimări cu iz de zicale, de tipul: ”Forța
este mai bună decât slăbiciunea”, ”Curajul este mai bun
decât lașitatea”, ”Bucuria este mai bună decât vina”,
”Onoarea este mai bună decât dezonoarea”, ”Libertatea
este mai bună decât sclavia”,
” Înrudirea este mai bună decât înstrăinarea”, ”Realismul
este mai bun decât dogmatismul”, ”Vigoarea este mai
bună decât lipsa vieții”, ”Familia este mai bună decât
universalismul”. Învățăturile de căpătâi sunt formulate
astfel: "tăria peste slăbiciune, mândrie peste umilință și
cunoaștere asupra credinței". Odiniștii slujesc zeii
educându-și "gândul, curajul, onoarea, lumina și
frumusețea". Odiniștii extremiști moderni sunt adepți ai
Wotanismului.
5. ORDINUL CAVALERILOR TEMPLIERI (11,12) a
apărut în anul 1119 (după prima cruciadă) cu misiunea de a
proteja pelerinii din Țara Sfântă; a fost recunoscut de către
Biserica Catolică. În timp, ordinul a ajuns deosebit de
bogat (au inițiat primele ”scrisori de credit”) și puternic.
Templierii s-au aflat uneori în conflict cu celelalte două
mari ordine creștine, cavalerii ospitalieri și cavalerii
teutoni (germanici); în condiții și circumstanțe istorice
specifice, cavalerii templieri au pierdut, în anul 1302,
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
toate teritoriile din Țara Sfântă; în următorii 200 de ani au
devenit o putere socio-economică, situație ce a creat
condiții ca regele Franței, în anul 1307, să ordone arestarea
și executarea capilor ordinului iar Papa să emită bula prin
care ordona arestarea templierilor din toată Europa și
confiscarea averilor. În anii 1700, în Scoția, —ritualul
York a încorporat unele simboluri și ritualuri ale
templierilor; au constituit o filială, existentă și astăzi,
numită (în prezent) ”O—rdinul Cavalerilor Templieri -
S—uveranul Ordin Militar al Templului din Ierusalim”
(fondat în anul 1804); ordinul are statut de organizație
caritabilă non-guvernamentală, recunoscută de către
ONU (din anul 2004 există și în România o priorie a
Ordinului Suprem Militar al Templului din Ierusalim -
OSMTH). Printre caracteristicile (cu valoare de simbol)
Ordinului Templierlor se numără îmbrăcămintea și crucea
roșie specifică (simbol al martiriului, moartea în luptă
fiind o mare onoare); Anders Breivik a desenat pe
manifestul său o cruce roșie asemănătoare cu cea a
templierilor și a afirmat că era pregătit să fie omorât (în
timpul prinderii sale sau ulterior).
6. MASONERIA (13,14) este „o asociație de oameni liberi
și de bune moravuri care conlucrează pentru binele și
progresul societății prin perfecționarea morală și
intelectuală a membrilor săi” iar ca instituție, este un ordin
inițiatic ai cărui membri sunt înfrățiți prin idealuri comune
morale, spirituale și sociale, prin inițierea conformă unui
ritual comun, prin jurământul depus pe una din cărțile
sfinte ale marilor religii (Biblia, Coranul, Dao de Jing,
Vedele hinduse, Tripitaka budiste, sau alte scrieri
considerate sacre) și, în majoritatea ramificațiilor, prin
credința într-o „Putere Supremă“ spusă „Mare Arhitect al
Universului“. Organizații masonice se află în majoritatea
țărilor lumii; conceptele teoretice sunt generoase,
umanitare, tolerante; astfel sunt excluse concepțiile de tip
extremist dar ideologia comunistă respinge masoneria
(unul din aspectele care l-a atras, probabil, și pe Anders
Breivik care s-a declarat anticommunist). Organizațiile
masonice se întâlnesc sub forma ”obediențelor
autonome”, ”mari loje” sau ”Mare Orient”; acestea sunt
compuse din ”loji albastre” numite și ”ateliere” de câte 7 –
50 de persoane; ierarhizarea ”clasei lojilor albastre”
prevede trei grade (ucenic, calfă / companion și meșter /
maestru). Cele mai răspândite rituri sunt ”Ritul York” și
”Ritul Scoțian Antic și Acceptat”. Masoneria are un
caracter cvasiezoteric prin îmbrăcăminte, ritualuri,
simboluri a căror origine și înțelesuri rămân, practic,
necunoscute chiar majorității membrilor săi (în funcție de
gradul care îl deține în cadrul ierarhiei); de aici și interesul
pentru ”mister” al unei largi categorii de oameni dar și
incapacitatea de a înțelege, accepta sau a aprecia
”normalitatea” practicanților a altor categorii; există
posibilitatea ca după accederea în ”interior” sistemul
valoric să nu mai mulțumească pe noii adepți (mecanism
psihologic posibil și la Anders Breivik).
7. EURABIA (15,16) – neologism politic care definește o
”teorie a conspirației a elementelor globalizante,
presupuse a fi conduse de puteri franceze și arabe, de a
islamiza Europa, slăbind astfel cultura existentă”; teoria a
devenit mai acceptată după septembrie 2011. Anders
Behring Breivik, în manifestul ”2083: Declarația
europeană de independență”, susține, pe larg, teoria
"Eurabia". În verdict cu Breivik, instanța a menționat:
"mulți oameni împărtășesc teoria conspirației lui Breivik,
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Gabriela Costea: ABB – criminalul morvegian. Psihoză versus psihopatie - analiză medico-legală psihiatrică
inclusiv teoria Eurabia. Curtea constată că foarte puțini
oameni împărtășesc ideea lui Breivik că presupusa"
islamizare "ar trebui să fie combătută cu teroare".
8. ORGANIZAȚII NEOFASCISTE: Ulterior, anders
Breivik s-a identificat ca susținător al conceptelor fasciste
/ neonaziste și a afirmat că anterior discursul său de tip
contra-jihad a fost necesar în vederea protejării
”etnonaționaliștilor”.
9. SERIAL KILLER, MASS-KILLER, SPREE-KILLER
În funcție de domeniul specialiștilor care abordează tema
violenței și a crimelor de omor, există o multitudine de
clasificări ale ”ucigașilor”. Pentru economia articolului nu
sunt necesare discuțiile privind omorul patologic / omorul
nepatologic. Raportat la crimele comise de către Anders
Breivik, referirea se face la ucigașii în serie, ucigașii în
masă (ucideri multiple) și la ucigașii ”de ocazie” / ”de
sindrofie” ( ucideri multiple). Trebuie să reținem că la
ucigași, de regulă, se descrie o stare de ”tensiune”
antefaptică urmată de o ”stare de liniște” postfaptică (ceea
ce explică și dificultățile de interpretare a testărilor
psihologice. Pentru difernțiere operațională se redau
definițiile general acceptate și agreate de către FBI.
”Ucigașii în serie” sunt acei ucigași care comit ”o serie” de
crime de omor pe o perioadă lungă de timp - uneori, de-a
lungul deceniilor; frecvent se constată un pattern al
modului de comitere și (mai rar) al tipologiei victimelor;
ucigașii nu au beneficii materiale (ca la alți ucigași cu
crime multiple de tip ”asasini plătiți”); sunt prinși cu
dificultate. Studiile multidisciplinare au conchis că aceste
crime sunt comise ”cu discernământ”. Ucigașul ”în
masă” comite ucide, ”pe scară largă”, (ex. masacrul
Columbine), cu intenție, un număr mare de oameni aflați,
la un moment dat, într-un singur loc. De la caz la caz, se
poate delimita, uneori, o motivație care ar putea fi
caracterizată ca patologică. (totuși, în aceste situații,
numărul victimelor este, de regulă, mai mic). ”Spree
killer” (ucigaș ocazional, ”de sindrofie”) omoară un
număr mare de oameni în două (teoretic, posibil și mai
multe) locații diferite, într-o perioadă scurtă de timp (după
prima ”crimă” nu a intervenit perioada de ”liniște” /
”relaxare”). Se discută, la acest tip de ucigași, dominanța
mecanismelor psihologice în detrimentul celor
sociologice. Mai mult, se consideră că orientarea spre o
modalitate sau alta de a comite un omor (mai ales mod
”spree” sau mod ”mass” ar putea fi relaționată și cu tipul
de model matern, intrând în discuție implicarea relației
gen-personalitate în comportamentele heteroagresive.
Precizările cu privire la definire și diferențiere a acestor
crime de omor au fost elaborate de către anchetatori
criminaliști (17). În practică, exceptând caracteristicele
cheie, apare dificil de diferențiat (mai ales în ceea ce
privește ”omorul în masă” față de ”spree murder”). Anders
Breivik a comis crimă de omor în centrul capitalei și după
aproximativ două ore pe o insula dar a motivat prin eșecul
primei acțiuni, subliniind că avea și planul ”B” (pentru
situația menționată), insula fiind aleasă rațional (era o
tabără de vară a tineretului muncitor – adică tineri cu
orientare de stânga). Din punctul de vedere al psihiatriei
medico-legale, aparent, este mai puțin important dacă la
Anders Breivik a fost un ”spree killer” sau ”mass killer”,
contând conotațiile psihiatrice în raport cu legislația
Norvegiei.
10. EXPERTIZA MEDICO-LEGALĂ PSIHIATRICĂ
10.1. Psihiatria medico-legală este un segment al
38
psihiatriei, dar cu statut autonom (operează cu categorii
științifice proprii raportate la un subiect limitat, dispune
de metodologii specifice de lucru, stabilește o identitate
științifică între constructele elaborate și realitatea faptică /
juridică prin criterii științifice delimitate și prin
argumentare logică) (18, 19, 20). Practic, psihiatria
medico-legală operează cu noțiuni precum capacitate
psihică, discernământ, periculozitate, competență psihică
specifică etc.; sintagmele specifice se analizează în raport
cu o faptă, în raport cu o situație juridică bine delimitată în
care este implicat un individ la un moment dat bine
stabilit; medicii stabilesc condiția psihiatrică / somatică /
psihologică apte de a modifica capacitatea psihică a
individului examinat (19,20,21,22,23,24). Psihiatria
medico-legală are funcții descriptive și evaluative
(25,26,27,28,29,30) precum și funcții epistemice (a logicii
științifice) care implică aplicarea conceptului ”medicina
bazată pe dovezi” (31), ”articularea gândirii medico-
biologice cu gândirea social-juridică” (18,20,32),
stabilirea legăturii de cauzalitate între statusul psihiatric și
comportament exprimat prin implicație juridică (18),
integrarea dimensiunilor medicale, antropo-culturale și
socio-juridice într-un concept unic (18,20). Practic,
speciliștii în psihiatria medico-legală se referă, în
principal, la un status psihiatric ”atunci și acum” (la
momentul implicării judiciare și la data examinării), la
periculozitatea pendinte de statusul psihiatric și la
necesitatea instituirii, sau nu, a unor măsuri medicale;
concluziile sunt argumentate, pe model integrat
multidisciplinar, și răspund la obiectivele instituției care a
solicitat opiniile medicale.
10.2. În toate țările lumii se efectuează expertize medico-
legale psihiatrice, atât în spețe penale cât și în alte spețe;
acestea sunt reglementate legal, cadrul de efectuare a
acestora depinzând de legislația și jurisprudența fiecărei
țări (33). (Tabelul nr. 1)
Specialiștii care pot efectua expertize medico-legale
psihiatrice dispuse oficial sunt, de regulă, medici psihiatri
dar, nu numai; persoanele numite pentru a efectua
expertize medico-legale psihiatrice, de regulă, au
certificate de ”competență” sau supraspecializare în
”psihiatrie medico-legală” (Tabel nr. 2, nr. 3). Experții
”independenți” sunt ”numiți” de către apărare dar
aprobați, pentru fiecare caz în parte, de către instanțe;
experții oficiali, în majoritatea țărilor sunt ”înscriși” pe o
listă de pe care sunt ”aleși” de către instituțiile care dispun
expertizarea. Codurile deontologice ale experților sunt,
sau nu, precizate oficial (exemple: Canada are
reglementări punctuale, bine precizate/delimitate; în
Regatul Unit al Marii Britanii și Irlandei de Nord codul
deontologic al experților ”independenți” era în curs de
finalizare în septembrie 2016). În România, în prezent,
calitatea de experți ”independenți” (”experți parte”) pot fi
(legal) doar medicii legiști dar, în anumite situații,
instituțiile care solicită acest tip de expertiză pot aproba,
pentru apărare, prezența la lucrările comisiei de
expertizare, a unui ”specialist psihiatru”. Reglementările
legale, în toate țările sunt mai clare în ceea ce privește
”experții oficiali” (Tabel nr. 2).
În anul 2005, Comisia Europeană pentru Sănătate și
Protecția Consumatorului a întocmit, în colaborare cu
Institutul Central de Boli Mintale de la Mannheim o
cercetare privind legislația si practica tratării infractorilor
bolnavi psihici, cercetare la care au participat 15 țări

membre UE, înainte de extensia din anul 2004 . Scopul
studiului a fost de a delimita prevederile legale si
conceptele, evaluările și practica de rutină, probleme ale
respectării drepturilor omului si pacienților, serviciile
medico-legale și date epidemiologice. Ca în orice astfel de
proiect, s-au obținut și informații adiacente, corelate logic
cu subiectul cercetării. Axiomatic, s-a considerat :
specialiștii în psihiatrie medico – legală sunt acele
persoane care se ocupă atât de tulburările mintale ale
infractorilor (sau ale altor persoane care au probleme
judiciare) cât și de istoricul lor infracțional / juridic, în aria
de competență intrând evaluarea stării mintale, întocmirea
unui raport scris, expertiza testimoniară, tratamentul
acestui segment de bolnavi, cunoașterea legislației privind
sănătatea mintală. (34). Sub aspectul cunoașterii
legislatiei se constată ca în cele 15 țări europene care au
participat la proiect, prevederile legale sunt pendinte
majoritar de Codul Penal Roman (exceptând Regatul Unit
si Irlanda), de sistemele naționale de sănătate și de
asigurările de sănătate, naționale sau private (Austria,
Belgia, Franta, Germania, Luxemburg, Olanda).
Terminologia vizând conceptele psihiatrice la care se
refera prevederile legale diferă (Tabel nr.1), are, frecvent,
caracter redundant și reflectă atât concepțiile fiecărei țări
cât și flexibilitate scazuta în acordarea la concepte
medicale moderne. Totuși, se remarcă efortul de asimilare
a unei nosologii mai apropiate celei moderne, mai ales pe
segmentele în care definitiile sunt acordate la instrumente
internaționale. În practică, ca expresie a unei bune
colaborari intre justitie si medicina, se folosesc,
obligatoriu, instrumentele ICD cu permiterea apelării și la
alte instrumente precum ”DSM”, experții acordând,
explicativ, aceste instrumente, la formularea concluziilor.
Expertizele / evaluarile sunt dispuse, in majoritatea țărilor
de catre instanțe. Marea majoritate a tarilor nu precizeaza,
i n l e g i s l a t i e , n r. d e e x p e r t i . ( t a b e l n r. 3 )
(35,36,37,38,39,40,41,42,43,44,45,46). In majoritatea
tarilor, expertii sunt medici psihiatri cu pregatire in
psihiatria medico – legala (pregătirea durând, de la țară la
țară, între 1 și 3 ani, medicii care se pregatesc pentru o
asemena specializare trebuind sa indeplineasca si alte
conditii).
In baza normelor legale prezentate sumar, se intocmesc
rapoarte de evaluare. In toate tarile enumerate, exista
prevederi legale cu privire la aceste rapoarte si la formatul
lor (33). Prevederile comune vizeaza cauzele in care se fac
evaluari, cu accent crescut pentru cauzele penale cu
infracțiuni de violență, maltratare – abuzuri fizice si
psihice – rele tratamente, cauze victimologice,
competența, capacitatea de a răspunde în fața instanței și
de a urma regimul de detenție fara repercursiuni negative
asupra sănătății psihice. Obligatoriu, in cauzele penale se
evalueaza potențialul agresiv, riscurile de comportament
violent si de recidivă. Obligatoriu, aprecierile asupra
riscurilor se fac de catre medici. In toate tarile se
precizează, pe larg, capitolul introductiv care cuprinde
date pașaportale ale persoanei examinate, modul de
adresabilitate privind persoana evaluata. Se stipuleaza
obligativitatea mentionarii surselor de informatii. In ceea
ce privește evaluarea psihiatrică, majoritatea țărilor nu o
detaliază prin norme legale dar ea trebuie efectuată în așa
fel încât să răspundă dezideratelor evaluării. Absența unei
detalieri impune respectarea standardelor psihiatrice,
prevazute de WPA, ceea ce înseamnă că se analizează, în
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
dinamică, personalitatea premorbidă (pornind de la
genitori), caracteristici comportamentale, atitudini
specifice, examinare pe functii, investigații și consulturi
interdisciplinare, investigații biologice, imagistice etc.,
examinări psihologice specifice, aplicare de scale
specifice, precizari diagnostice, opinii cu privire la caz,
recomandari, discuție de caz, concluzii privind
raspunsurile la obiective. Stiintific raportul reprezinta o
prezentare de caz. Raportul de evaluare are valoare
individuala si stiintifica generala. In toate tarile se
subliniaza atitudinea neutra a medicului si prudenta
deontologica (in cazurile penale, persoana evaluata se
poate apara prin negarea faptei, situatie care trebuie
reflectata in continutul raportului sau pacientul refuza
evaluarea, aspect ce, deasemenea se mentioneaza, fiind
urmata de descrierea comportamentului). Se constata,
astfel, ca diferentele apar mai ales in terminologie,
prevederi redundante, esenta continutului raportului fiind
similara in cele 15 tari. Tendinta actuala este de evaluare
cat mai aprofundata, cu accent pe analiza riscurilor si a
cazurilor victimologice. In ceea ce priveste formatul
rapoartelor, ca atare, tendinta este de specificitate pe grupe
de varsta, sex, tip de cauze, gravitatea faptelor. Se asteapta
de la aceste evaluari posibilitatea analizelor predictive.
10.3. În ceea ce privește formatul expertizelor
medico-legale psihiatrice (în speța analizată), atât în
România cât și în Norvegia se analizează / se solicită
aceleași informații (47,48,49) dar în Norvegia nu există
(ca în România) comentarii privind baza legală a
solicitărilor experților și nici nu se impune efectuarea
expertizei în baza doar a anumitor documente sau a
anumitor pagini. În Norvegia, experții alcătuiesc planul
activității de expertizare și, comform normelor legale,
acționează direct în vederea obținerii informațiilor
necesare; în România, experții nu se pot implica activ
(exceptând documentația medicală psihiatrică cu privire
la care există prevederi legale) în obținerea informațiilor;
ca atare, rol activ, în acest sens, îl pot avea doar instituțiile
care solicită expertiza. Astfel, în speța ”Anders Breivik”,
formatele expertizelor medico-legale psihiatrice
(comparativ Norvegia – România) arată astfel:
10.3.1. PRIMA EXPERTIZĂ MEDICO-
LEGALĂ PSIHIATRICĂ – NORVEGIA: 1. Formalități /
1.1 Mandatul / 1.2 Taxe / 2. Documentația de bază / 2.1
Evaluarea documentelor de poliție care trebuie raportate
în declarația psihiatrică legalizată / 2.2 Observație
preliminară / 2.3 Declarațiile victimelor / 2.3.1 Victimele
legate de actele criminale de către clădirile guvernului /
2.3.2 Victimele legate de actele criminale de la Utøya / 2.4
Declarațiile lui Breivik către poliție / 2.4.1 Explicație din
22 iulie 2011, doc. / 2.4.2 Rezumatul incarcerii 23 iulie /
2.5 Rezumatul interogării persoanei aflate sub observație
pe DVD 20 / 2.5.1 Interogarea înregistrată pe CD din data
de 22 iulie 2011 20 / 2.5.2 Interogarea în continuare a
persoanei aflate sub observație înregistrată pe DVD 21 /
2.6 Examinarea martorilor / 2.6.2 Martor XXXXX,
jumătate sora din partea tatălui persoanei aflate sub
observație, doc. / 2.6.3 Martor, XXXXX, cel mai apropiat
prieten al persoanei aflate sub observație, doc. /2.6.4
Martor XXXXX, prieten al persoanei aflate sub
observație, / 2.6.5 Martor XXXXX, prieten al persoanei
aflate sub observație, / 2.6.6 Martor XXXXX, prietena
unui prieten al persoanei aflate sub observație, / 2.6.7
Martor XXXXX, prieten al persoanei aflate sub
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Gabriela Costea: ABB – criminalul morvegian. Psihoză versus psihopatie - analiză medico-legală psihiatrică
observație, / 2.6.8 Martor XXXXX, prieten al persoanei
aflate sub observație, /2.6.9 Martor XXXXX,
cunoașterea persoanei aflate sub observație, / 2.6.11
Martor XXX, fost prieten, / 2.6.12 Alți martori cu
cunoștințe personale ale persoanei aflate sub observație /
2.6.13 Martorii pe continent (Utøya doc 09,01,01,
09,01,02 și 09,01,15) / 2.6.14 Utøya: Raportul șefului
operațiunii de poliție Gåsbakk, doc. 07,01,01 / 2.7
Serviciul de bunăstare a copilului / Serviciul de asistență
socială / Psihiatria copilului și adolescentului / 2.7.1 Caz
de îngrijire a copilului 1981-1984 2 /2.7.2 Cazul custodiei
copilului 1983 / 2.7.3 Cazul de îngrijire a copiilor 1994-
1995 / 2.8 Compendiu scris de subiect, denumit și
manifestul / 2.8.1 Ipoteze pentru revizuirea de către
experți a compendiului / 2.8.2 Observație importantă: /
2.8.4 Considerații speciale / 2.9 Avizul expertului din
partea Autorității de Sănătate Publică privind intoxicația /
2.10 Raport Laborator (Laboratorul norvegian pentru
analize doping) / 2.11 Scrisoare adresată mamei de la sora
subiectului, din 2009 sau 2010 / 3. Informații obținute / 3.1
Medicul generalist XXXXX / 3.2 Urmărirea serviciului
de sănătate la închisoarea Ila / 3.3 SC SCAN / 4. Interviuri
cu persoane care cunosc tema / 4.1 Interviu cu mama
subiectului de către ambii experți la 14 august 2011 / 4.2
xxxxxxxxxxxxxx / 5. Contextul și mărturia subiectului /
5.1. Primul interviu acordat ambilor experți la 10 august
2011. / 5.2 Al doilea interviu efectuat de ambii experți la
12 august 2011 / 5.3 Al treilea interviu efectuat de către
ambii experți la 23 august 2011 / 5.4 A patrulea interviu
efectuat de ambii experți la 25 august 2011 / 5.5 Cel de-al
cincilea interviu efectuat de ambii experți la 30 august
2011/
5.6 Cel de-al șaselea interviu acordat ambilor experți la 1
septembrie 2011 / 5.7 A șaptea conversație cu ambii
experți la 5 septembrie 2011 / 5.8 Cea de-a opta
conversație cu ambii experți, la 13 septembrie 2011 72
/5.9 Cea de-a noua conversație cu ambii experți din 16
septembrie 2011/ 5.10 A zecea conversație cu ambii
experți la 20 septembrie 2011 78
5.11 Cea de a unsprezecea convorbire cu ambii experți la
22 septembrie 2011 / 5.12 A douăsprezecea conversație cu
ambii experți la 2 noiembrie 2011/ 5.13 A treisprezecea
conversație cu expertul Husby la 21 noiembrie 2011/ 6.
Psihometrie / 6.1 Selectarea Testelor / 6.2. Evaluarea
globală a funcționării (GAF) / 6.4 SCID 1 / 6.5 MADRS /
6.6 YMRS / 7. SINTEZA / 8. DISCUȚIE / EVALUARE /
8.1 INTRODUCERE / 8.3 RĂSPUNSUL DETALIAT LA
MANDAT / 9. CONCLUZIE .
10.3.2. A II – a EXPERTIZĂ MEDICO-
LEGALĂ PSIHIATRICĂ – NORVEGIA: 1. Formalități /
2. Observații generale / 3. Mandatul / 4. [cenzurat] / 5.
Extrase din documentele relevante / 6. Documentația de
aprobare (ministere) / 7. Testele privind utilizarea clinică
și avizul experților / 8. Interogarea acuzatului / 9.
Manifestul / 10. Condiții economice / 11. Interogarea
familiei, etc. / 12. Interogarea prietenilor / faimosilor /
cunoscuți
13. Intrebarea martorilor / victimelor, diverse / 14.
Informații privind sănătatea / 15. Observarea forțată a
actului de procedură penală / 16. Ideologie, istorie și
politică / 17. Examinarea de către experți a observațiilor /
18. Investigații suplimentare / 19. Psihometrie /
20. Rezumat / 21. Evaluarea diagnosticului / 22.
Răspunsul mandatului / 23. Sub rezerva declarației
40
medico-legale privind psihiatria / 24. Concluzie.
10.3. NOUA EXPERTIZĂ MEDICO - LEGALĂ
PSIHIATRICĂ – ROMÂNIA: Preambul (comform prev.
Codului de procedură)/ A. Istoric comform documentației
înaintate / I. Motivarea solicitării unei noi expertize
medico-legale psihiatrice / II.. Obiectivele expertizei / III.
Istoricul faptei / 1. Comportament antefaptic / 2. Mod de
comitere a faptei / 3. Comportament postfaptic / IV.
Declarațiile expertizatului în fazele de anchetă / judecată /
V. Declarații martori / VI. Antecedente penale / VII.
Consum de substanțe psihoactive / VIII Evaluări / anchete
sociale / IX. Alte informații privind istoricul / X.
Documente medico-legale/ XI . Documente medicale / B.
Constatările comisiei / I. Date anamnestice și de
personalitate premorbidă / II. Internare în vederea
expertizării (dacă este cazul) / III. Examenul stării psihice
prezente / IV. Investigații complementare / C. Discuția
cazului / D. Aprecieri asupra periculozității / riscurilor
(inclusive de recidivă) / E / recomandări special (dacă este
cazul) / F. Răspunsuri punctuale la obiective / Concluzii.
Deoarece, în România, experții nu au rol activ în
obținerea informațiilor, formatul prevede (din motive
deontologice) separarea netă a informațiilor avute la
dispoziție (înaintate initial și/sau solicitate și primate) de
constatările comisiei; discuția cazului este integrată. În
România obiectivele sunt formulate de către instituția care
solicită expertiza în timp ce în Norvegia obiectivele se
referă la articole de lege.
CAZUL ANDERS BEHRING BREIVIK
Deoarece cele două expertize medico legale
psihiatrice au un total de aproximativ 250 de pagini nu le
vom prezenta în baza propriilor structuri ale acestora ci în
baza ”faptelor”, prezentarea fiind organizată,
aproximativ, comform formatului românesc.
I. GENERALITĂȚI
La data de 22 iulie 2011, Anders Breivik a parcat o
mașină încărcată cu explozibili în fața Biroului primului
ministru norvegiande la Oslo și a detonat explozibilul; în
explozie au fost uciși 8 oameni; a parasit locația și a plecat,
înarmat, pe insula Utøya unde se afla o tabără a Ligii
Tinerilor Muncitori; a început să tragă, ucigând 69 de
tineri cu vîrste cuprinse între 15 și 19 ani. La sosirea
polițiștilor s-a predat. A fost arestat imediat. În aceeași zi,
anterior atacului din Oslo, Anders Breivik a lăsat pe P.C.
un ”manuscris” caracterizat de către autor ca fiind
”manifest politic” și denumit ”2083 – O declarație
europeană a independenței”; manifestul fusese diseminat
și pe internet.
Anders Breivik s-a născut la Oslo, la data de
13.02.1979; mai este cunoscut sub numele de Anders
Berwik, Sigurd Jordalfare (în cadrul ”Ligii Norvegiene de
Apărare” ) și Andersnordic (în cadrul organizației ”World
of Warcraft”). La data arestării s-a declarat adept al
Bisericii Creștine Norvegiene.
La data de 28.07.2011, Curtea Districtuală Oslo a
dispus efectuarea unei expertize medico-legale
psihiatrice; dispoziția a fost complectată la data de
11.08.2011; la data de 29.10.2011, raportul a fost înaintat
Curții (cu precizarea că în perioada de efectuare a
expertizei, cei doi medici psihiatri nu au mai avut altă
activitate). În mod normal rapoartele de expertiză medico-
legală psihiatrică nu sunt publice dar sub presiunea
populației atât rapoartele cât și rechizitoriul au fost
publicate.

II. PRIMUL RAPORT DE EXPERTIZĂ
1. Obiectivele raportului au fost precizate comform
legislației norvegiene (47):
”1. Experții sunt rugați să ia în considerare elementele
enumerate mai jos, ca parte a unui examen psihiatric
criminalistic. Experții pot coopera în pregătirea
declarației scrise, dar se presupune că aceștia fac evaluări
independente. Trebuie să fie descris în mod clar modul în
care experții au lucrat și în ce domenii pot avea evaluări
diferite. Trebuie să existe o referință sursă pentru toate
informațiile incluse în declarație (de exemplu, informații
din documentele de caz, dosarele de sănătate și persoanele
care cunosc persoanele aflate sub observație [în
continuare Breivik, remarca traducătorului]). Toate
concluziile trebuie să fie justificate. Incertitudinile din
evaluări ar trebui subliniate. Dacă experții trebuie să își
bazeze aprecierea asupra perceperii faptelor cauzei, care
nu sunt ușor evidente din documente sau care pot fi incerte
sau contestate, acest lucru trebuie menționat explicit.
Apoi, ar trebui să apară și dacă evaluarea experților ar fi
fost diferită dacă s-ar fi aplicat un alt fapt. Dacă este nevoie
de investigații suplimentare pentru a identifica premisele
evaluării psihiatrice medico-legale, experții pot contacta
procurorul poliției Kraby la districtul de poliție din Oslo.
2. Experții vor examina clinic viața lui Breivik înainte, în
timpul și după faptele infracționale, cu un accent special
pe comportament, inclusiv funcționarea psihologică și
socială și orice posibilă evoluție a bolii, precum și
tratamentul. Trebuie obținute informații relevante. Cea
mai recentă versiune a sistemului internațional de
diagnosticare (trecut ICD-10) trebuie utilizată pentru
diagnosticarea și diagnosticul diferențial relevant pentru
evaluarea psihiatrică medico-legală. Dacă mandatul
conține întrebări referitoare la prognoză, experții trebuie
să descrie în mod specific metoda utilizată în cadrul
anchetei și care sunt posibilele surse de eroare. Dacă este
necesară o investigație sau o testare suplimentară pentru a
răspunde mandatului, experții sunt rugați să realizeze
acest lucru. Dacă experții sunt de părere că un alt expert ar
trebui să efectueze un astfel de raport intermediar,
autoritatea delegatoare trebuie să fie contactată pentru
aprobare. Evaluarea sancțiunii și posibilele motive pentru
reducerea sancțiunilor
3. Experții sunt rugați să ia în considerare dacă Breivik a
fost psihopat, inconștient sau handicapat mental într-un
grad înalt la momentul actelor criminale (Codul Penal §
44).
4. În cazul în care experții concluzionează că Breivik nu
era într-o situație menționată la alineatul (3), trebuie să ia
în considerare dacă Breivik la momentul faptelor
infracționale:
A avut o tulburare mentală gravă, cu o capacitate
semnificativ afectată de a evalua realist relația sa cu lumea
exterioară, deși nu a fost psihotică sau a fost retardat ușor,
sau a acționat sub o perturbare puternică a conștiinței
(Codul penal § 56 c).
5. Dacă experții cred că Breivik la momentul actelor
criminale a avut o perturbare a conștiinței care intră sub
incidența Codului Penal, §§ 44 sau 56 c, motivul
(motivele) pentru aceasta trebuie să fie investigat. Experții
nu trebuie să se pronunțe asupra faptului dacă perturbarea
conștiinței a fost provocată de sine.
6. Experții sunt rugați să ia în considerare dacă Breivik a
fost psihotic la momentul investigației. În plus, dacă se
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
aplică sancțiunile speciale în caz de nebunie psihică
7. Dacă experții consideră că Breivik era într-o stare
descrisă în Codul Penal § 44 sau dacă există îndoieli în
legătură cu acest lucru, ei sunt rugați să investigheze
prognosticul bolii / afecțiunii. Experții sunt rugați să ia în
considerare ce tratament și ce alte măsuri sunt necesare
pentru a obține un prognoză optimă, îmbunătățirea pe care
o poate realiza și timpul necesar pentru aceasta. Sprijinul
pe care Breivik îl poate obține din sistemul de sănătate va
fi examinat în mod special. De asemenea, experții sunt
rugați să examineze prognosticul, inclusiv riscul viitoarei
violențe, dacă Breivik nu primește un astfel de tratament /
urmărire”.
2. Concluziile raportului
Experții au concluzionat că ”acuzatul” prezintă
”psihoză paranoidă”, a fost psihotic la data comiterii
faptelor și în perioada examinărilor (în număr de 13) și
prezintă pericol de sinucidere și de heteroagresivitate.
3. Experții își susțin concluziile astfel:
3.1. Examinări psihiatrice: la toate interviurile, experții au
constatat absnța modificărilor perceptuale, existența unor
idei de supraevaluare, absența simptomelor depresive,
abesnța empatiei, modificări de limbaj, în sensul ”crearii”
unor ”noțiuni” (cuvinte neuzuale în vocabularul
norvegian). În ceea ce privește personalitatea premorbidă,
experții s-au referit doar la faptul că, în copilărie, a fost în
atenția serviciului social dar fără a se lua hotărârea de a fi
asistat de către stat. Experții au luat notă de antecedente de
abuz de steroizi. Examinările psihologice dispuse au
constat doar în SCID I (secțiunea referitoare la ”psihoze”,
teste privind afectivitatea (ex. MADRS)(?); experții au
apreciat GAFS = 23 (?). Discuția cazului a fost făcută pe
modelul DSM IV (cu detalierea tuturor ”modulelor”) dar
în concluzii se referă la ICD 10. Concluziile sunt stufoase,
reluând informații din conținutul raportului (un total de
104 pagini) și din ”discuția cazului”. Aprecierile
psihiatrice nu sunt susținute de exemplificări
3.2. Aprecieri cu privire la ”Manifest” și susținerea ideilor
de grandoare și ”paranoia”:
” Experții subliniază faptul că nu au luat poziție cu privire
la mesajul politic sau la punctul de vedere al subiectului.
Acest lucru este, evident, dincolo de mandatul experților.
De asemenea, experții nu au calificări pentru a evalua
calitatea literară a compendiului sau calitatea materialelor
pe care le-a citat sau le-a produs în alt mod. Pentru experți,
în compendiu a fost o preocupare egocentrică, care a avut
importanță și interes, și anume importanța percepută a
subiectului, atît derivată direct din evenimentele istorice,
cît și importanța sa ulterioară, dată de sine, pentru Europa
și lume. …. Experții au fost imediat nedumeriți de
conceptul compendiului. Subiectul a proclamat intenția
…. salvarea Europei de la multiculturalism și preluarea
islamică și el a spus experților că răspândirea
compendiului a fost scopul său final al întregii operații. Cu
toate acestea, el a avut mai multe abordări față de acesta
din urmă. … experții consideră că este rezonabil să pună la
îndoială motivele pentru care a fost elaborat un astfel de
text. …. Modul în care acest lucru apare experților,
compendiul, atât în ​ansamblul său, cât și în detaliu, … dă
suspiciuni clare despre iluzii de bază și subiacente de
grandoare. O astfel de egocentricitate poate fi foarte bine
explicată ca o funcție a lipsei distanței și a autocriticii în
amăgirea de bază a măreției. Acest lucru se reflectă în
modul în care subiectul își tratează importanța și felul în
41
Gabriela Costea: ABB – criminalul morvegian. Psihoză versus psihopatie - analiză medico-legală psihiatrică
care, în cele din urmă, ajunge să se numească ca moașă a
noii ere și a noii Europe. … atenția și interesul experților
au fost secțiunile privind proiectarea și construcția
comunității pe care el o descrie ca fiind Cavalerii
Templieri, …. Experții observă pasiunea și fascinația
evidentă cu care subiectul teoretic "construiește" o
organizație cu premii și decorațiuni până la cele mai mici
detalii. Inspirat în primul rând de tradiția militară a SUA,
el folosește o mulțime de timp și spațiu pentru a crea o
glorificare ierarhică a eroilor și a martirilor, de asemenea
în conformitate cu martiriul islamic și pe un fundal
medieval. …. În compendiul său, subiectul se descrie ca
având o importanță națională viitoare în calitate de
comandant național al Marelui Maestru Cavaler sau o
importanță europeană - comandant pan-european al
Marelui Cavaler. Subiectul a dobândit un fel de uniformă
și, cu toată seriozitatea, a fost fotografiat, decorat cu
medaliile pe care el crede că le merită. Imaginea face parte
din concluzia compendiului și este pusă împreună cu poze
ale lui în poziția de luptă. …. Pentru experți, părțile
interviului care se concentrează asupra clarificării
detaliate a opiniilor politice ale subiectului sunt de o
importanță mai mică. …. Descrierile subiectului amintesc
de figurile istorice / religioase anterioare ….”; Experții
citează din ”manifest”: ” Întotdeauna voi ști că sunt
probabil cel mai mare campion al conservatorismului
cultural, pe care Europa l-a avut vreodată din 1950. Sunt
unul dintre multele distrugătoare ale marxismului cultural
și, ca atare, un erou al Europei, un salvator al poporului
nostru și al creștinismului european - implicit. Un
exemplu perfect care trebuie copiat, aplaudat și sărbătorit
… mi-am dorit întotdeauna să fiu cavalerul perfect. Un
Justice Knight este un distrugător al multiculturalismului
și, ca atare, un distrugător al răului și un purtător de
lumină. Voi ști că am făcut tot ce am putut pentru a opri și a
inversa genocidul cultural și demografic european și
pentru a pune capăt islamizării Europei”. Experții
comentează: ” compendiul poate apărea similar cu modul
în care salvatorii anteriori au fost descriși în cărțile
asociate. Se poate vedea asemănarea cu Biblia, care este,
de asemenea, împărțită în cărți diferite. Compendiul
conține numeroase descrieri care evocă asociații cu iluzii
religioase, cum ar fi grandoarea. Exemple sunt cei 12
fondatori ai Templului Cavalerilor din Londra (care
amintesc de cei 12 discipoli ai lui Isus), ispitele altora,
aspectul salvării, pregătirea pentru martiriu și împărțirea
unei sticle de vin cu rudele apropiate înainte de martiriu.
…”. (de remarcat că experții au crezut ca Breivik se referă
la o persoană și nu la prioria cavalerilor templieri din
Londra). …. Fără a intra în hotărârile politice ale
subiectului, experții observă că percepția sa asupra stării
Europei și a statului Norvegiei este extremă. Multe dintre
interpretările și afirmațiile sale nu sunt fundamentate.
Totuși, se pare că cea mai mare parte a acestui material este
mai degrabă o aplicație a curenților politici existenți decât
o creație proprie, deoarece multe dintre ele sunt tăiate și
lipite de pe diferite site-uri web și surse istorice. Aceasta
înseamnă că citatele și concluziile sale sunt împărtășite de
un număr de persoane din Norvegia și din alte părți ale
Europei.
Cu toate acestea, experții sunt afectați de intensitatea
terminologiei de război a subiectului și de experiența și
descrierea sa de a fi într-un război care duce la actele
criminale. Experții pot constata, atât în ​compendiu, cât și
42
prin contactele cu el în conversațiile noastre și în cursul
interogatoriului, că de fapt, atât din punct de vedere
emoțional, cât și în realitate are percepția despre război,
distrugere și propria sarcină de salvare. Subiectul se
descrie ca fiind într-o situație cu doar două rezultate:
distrugerea culturii și a existenței sale sau mântuirea prin
martiriul și victoria pe termen lung, cu victoria finală din
anul 2083”. (NOTĂ: manifestul are aproape 1800 pagini)
3.3. Experții afirmă: ”Subiectul nu este capabil să
recunoască sau să-și descrie propriile sentimente. Apare
astfel cu alexitimie și expresie emoțională proeminentă.
… Subiectul crede că motivul pentru execuții este de a
reorganiza scara politică. El se așteaptă ca acțiunile sale să
conducă la simpatia și sprijinul milioanelor de europeni și
că politicile sale vor fi orientarea politică dominantă a
viitorului. Ideile sunt considerate ca iluzii grandioase.
El subliniază faptul că motivul principal al uciderilor a
fost că operațiunea îmi exprimă iubirea față de poporul și
țara mea și va contribui la eliminarea răului din țară. El
crede că, în ciuda riscului perceput pentru propria viață, s-
a sacrificat pentru poporul său. El crede că înregistrările
acțiunilor sale în această perioadă vor oferi îndrumări
pentru acțiuni similare viitorilor revoluționari. Ideile sunt
considerate ca iluzii grandioase. … El a avut planuri
diferite, inclusiv aruncarea în aer a clădirii guvernului,
detonarea la castelul regal și uciderea familiei regale,
uciderea Blitzers, ziarul Dagsavisen și la sediul partidului
socialist. El descrie, de asemenea, gânduri persistente cu
privire la declanșarea convenției naționale a Partidului
Laburist și a conferinței pentru jurnaliști din cadrul
Grupului…. Experții au întâmpinat ocazional dificultăți în
urmărirea subiectului. În unele părți ale conversației, el
pare să aibă o tulburare moderată de asociere și o tulburare
de gândire formală sub forma perseverenței. Nu există o
latență sau un blocaj de gândire în timpul conversației.
Subiectul apare complet fără gânduri depresive sub formă
de vină, rușine, deznădejde sau gânduri despre propria
moarte prin sinucidere. El neagă experiența tristeții, lipsa
de bucurie, inițiativa redusă sau lipsa de inițiativă. Nu
există, așadar, nici o dovadă de stare depresivă. …
Discursul subiectului este coerent și cu o sintaxă normală.
El este "afectiv stabil". Nu există nici o dovadă de lipsă de
control al impulsurilor, nici verbal, nici fizic. Nu există,
așadar, nici o dovadă a unei dispoziții ridicate.Subiectul
apare fără suspiciune clinică de a fi intoxicat. Subiectul
neagă că are gânduri sau planuri de sinucidere”.
3.4. Aprecieri ale experților: ” Subiectul începe să
acționeze în conformitate cu amăgirile sale la începutul
anului 2010, cu achiziții și planificarea acțiunilor armate.
În ultimele optsprezece luni înainte de acțiunile criminale,
și-a dedicat tot timpul și atenția universului său delirant,
iar mama lui confirmă simptome extinse, comportament
vizibil și lipsă de abilități de comunicare până la
evenimentele actuale. Subiectul recunoaște că a efectuat
acțiunile penale. Acțiunile sunt considerate a fi în corelație
directă cu lumea delirantă în care percepe că este într-un
război civil, cu amenințarea cu dispariția rasei sale,
precum și cu frica de violență și genocidul a ceea ce el
descrie ca popor al meu. El susține că are responsabilitatea
de a decide cine va trăi și va muri în țară. Universul său
extrem de egocentric, cu aproape toate ideile de măreție,
caracterizează toate aprecierile și aparența sa, indiferent
de context, și apoi devine forța motrice a acțiunilor sale
din 22 iulie 2011. Nu există dovezi ale modificărilor

abrupte sau intermitente ale simptomelor psihotice ale
subiectului în perioada anterioară evenimentelor actuale.
Astfel, nu există nici o dovadă că schimbarea simptomelor
subiectului a fost modificată ca urmare a administrării
steroizilor sau a stiva revigorantă a medicamentelor ECA
înainte de actele criminale. Pe baza descrierilor, experții
constată că manifestarea simptomelor sale rămâne
neschimbată înainte de acțiunile penale și de-a lungul
întregii investigații. Concluzia este că subiectul este
considerat a fi fost psihotic la momentul acțiunilor
criminale și că a fost psihopat în timpul observării”.
4. Concluzii finale: ” După efectuarea unei
examinări psihiatrice medico-legale a lui Behring Anders
Breivik, născut la 13/02/79, experții găsesc următoarele: I.
În ceea ce privește nebunia psihică (§ 44) 1. Subiectul a
fost psihotic la momentul actelor criminale;
2. Subiectul a fost psihotic în timpul observării; 3.
Subiectul nu a fost inconștient la momentul actelor
criminale; 4. Subiectul nu este întârziat mental într-un
grad înalt; II. PRIVIND CODUL PENAL § 56 C: 1.
Subiectul nu a acționat sub tulburarea puternică a
conștiinței; 2. Subiectul nu este retardat mental”
III. REACȚII LA RAPORT
Inițial,”Comisia medico-legală” din cadrul Consiliului
regal de Medicină Legală” nu a reacționat la conținutul și
concluziile raportului. Opinia publică și numeroși
psihiatri norvegieni și străini au criticat concluziile
raportului stipulând, în principal, nerecunoașterea de către
experți a subculturii ideologice extremiste; s-au sesizat și
contradicțiile din conținutul raportului (49). A fost
analizat, de către psihiatri / psihologi etc. ”manifestul”.
Personalul penitenciarului (inclusiv cadre medicale și
psihologi) au declarant că Anders Breivik nu are un
comportament ”psihotic”. Comisia medico-legală a
reanalizat raportul și informațiile și a dispus efectuarea
unei alte expertize.
IV. EXAMINATUL ANDERS BREIVIK
Din informațiile trecute în revistă se pot sintetiza
următoarele:
1.Informații relevante privind personalitatea premorbidă a
subiectului expertizei:
S-a născut la Oslo, din familie organizată (tatăl economist
la ambasada Norvegiei de
la Londra, mama asistentă medicală); primul an a locuit la
Londra; părinții divorțând a rămas în grija mamei fiind
crescut și educat la Oslo. A fost un elev mediocru. În jurul
vârstei de 11 ani a prezentat tulburări de conduita, fiind
monitorizat de instituțiile de protectie a copilului și
adolescentului; nu s-a luat măsura de scoatere din familie.
Ambii părinți s-au recăsătorit având frați de la ambii
părinți (relațiile fiind inconstante, în funcție de
comportamentul său). În jurul vârstei de 15 ani a intrat
într-un anturaj nefavorabil și a prezentat tulburări de
conduită dar a fost o singură dată cercetat de poliție fără a
fi sancționat / pedepsit; a renunțat singur la acest anturaj;
după aceste evenimente, relațiile cu tatăl (stabilit în
Franța) s-au intrerupt (fiecare afirmând că celălalt le-a
intrerupt). Un coleg a afirmat că susnumitul i-a povestit,
în detaliu, cum a chinuit o pisică dar A. Breivik. a negat. A
absolvit liceul economic. La 20 de ani a câștigat ”primul
million” din ”afaceri”; ulterior a mai câștigat dar a și
pierdut mulți bani prin afaceri riscante (acest aspect a fost
probat și nu poate fi caracterizat ca idei de tip expansiv sau
mitomanie). A trăit mai mult din expediente. A locuit cu
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
mama până în anul 2009. Din adolescență a consumat
steroizi pentru ”condiție fizică” (cerințe ale odiniștilor); a
jucat, exagerat jocuri video (World of Warcraft și Modern
Warfare 2); la vârsta de 30 de ani sora sa îi scria,
exasperată, mamei, că nu se lasă de acest ”viciu”. După 20
de ani a călătorit mult și a intrat în contact cu cercuri
extremiste; s-a înscris în Ordinul Cavalerilor Templieri
(varianta modernă) înaintând în ierarhie; și-a procurat
singur îmbrăcămintea (aspect simbolic al ordinului); a
cochetat cu ”odiniștii” dar ”nu s-a putut identifica cu
aceștia” deși a apreciat cultul martiriului. A activat ca
blogger extremist și a aderat la diferite grupări extremiste
(a se vedea capitolul ”introducere” de la începutul
articolului). În mediul virtual și al diferitelor grupări
extremiste europene era cunoscut ca un extremist sever
(”îi știam numele dar nu știam cine e”). A activat pe site-ul
”Document. no” cu nume real până în anul 2009 dar se
consideră că apoi a scris sub alt nume. Exemple de postări:
”musulmanii ca naziștii” … „Mi se pare ipocrit să tratezi
musulamnii, naziștii și marxiștii în mod diferit”, își
începea mesajul. „Sunt toți susținători ai ideologiilor
bazate pe ură. Nu toți musulmanii, naziștii sau marxiștii
sunt conservatori, cei mai mulți sunt moderați. Dar
contează asta? Un nazist moderat, să spunem, după ce s-ar
confrunta cu o fraudă, ar putea alege să devină
conservator. Un musulman moderat poate, după ce i se
refuză intrarea într-un club, să devină conservator etc. Este
clar că susținătorii moderați ai unor ideologii bazate pe ură
vor decide la un moment dat să devină conservatori.
Islamismul a dus la moartea a 300 de milioane de oameni,
comunismul la moartea a o sută de milioane, nazismul la
moartea a 6-20 de milioane de oameni. Toate ideologiile
bazate pe ură ar trebui tratate în mod egal”; ” Patriotismul e
numit azi extremist”; „Ce o să facă globalizarea și
modernizarea împotriva imigrării în masă a
musulmanilor”, ... „Sau poate n-ați auzit de Japonia sau
Coreea de sud? Aceste țări sunt exemple de succes și
regimuri moderne care au respins multiculturalismul în
anii 70. (...) Poți numi o singură țară unde
multiculturalismul a reușit unde a fost și islamul implicat?
Singurul exemplu istoric de succes al multiculturalismului
în societate sunt SUA, dar acolo minoritățile nu sunt
islamice”…. „Problema cu Europa este că a pierdut
Războiul Rece încă din 1950, din momentul în care le-au
permis marxiștilor/ anti-naționaliștilor să-și facă de cap
(...). Rezultatul, în Norvegia și Suedia este că atitudinea
marxistă extremistă a ajuns să fie acceptată zi de zi, în timp
ce fostul sistem de adevăruri patriotice și conservatorism e
numit azi extremist (de către marxiști și umaniști)”
(postare, 30 decembrie 2009) … ” „O zonă liberă de
musulmani este: 1. Acolo unde o femeie non-musulmană
beată se poate plimba pe stradă fără să fie amenințată cu
violul, jaful, hărțuirea, violența. 2. E un loc unde tinerii
care nu sunt musulmani se pot plimba fără să fie în pericol
să fie hărțuiți de găști de musulmani sau indivizi
musulmani. 3. E o zonă unde cei care nu sunt musulmani
se pot exprima liber, în cele trei forme (religios, sexual,
cultural) fără amenințarea iminentă că vor fi hărțuiți
psihologic”. S-a înscris în partidul norvegian de extremă
dreaptă dar a fost scos din evidență pentru neplata
cotizației. Asculta muzică cu tematică extremist –
naționalistă și violentă. Citea cărți cu aceeași tematică dar
engramarea acestora apare ca nepotrivită, nivelul de
”cultură” fiind submediocru (de unde uzitarea unui
43
Gabriela Costea: ABB – criminalul morvegian. Psihoză versus psihopatie - analiză medico-legală psihiatrică
amalgam de noțiuni). Necăsătorit, fără copii. Se descria
creștin, conservator, patriot, antifeminism, antimarxist,
antiislamic cu concepții antimulticulturale. Era pasionat
de vânătoare.
2.Comportament antefaptic general
În anul 2009 și-a cumpărat o fermă în estul Norvegiei,
folosită drept paravan pentru a comanda mari cantități de
nitrat de amoniu, (îngrășământ chimic, utilizat în
producerea de bombe artizanale).Era caracterizat drept
fermier ”de oraș” în sensul că nu se pricepea și nu se
preocupa de fermă. În această perioadă a scris
”manifestul” care exprimă cu claritate: antiislamismul,
antimulticulturalismul, antimarxismul și concepțiile
antifeministe; sub aspect ”literar” maniera este de
”blogger” cu concepte extremist – violente survenite pe un
nivel cultural general submediocru dar cu mare aderență la
”subcultura ideologică extremistă”. Pe acest manifest
apare crucea roșie cu caractere ”templiere”. În conținutul
manifestului este desenată o hartă a Europei cu notații
privind țări / orașe în care vor avea loc ”explozii”; harta
este însoțită de precizarea geografică (latitudine și
longitudine) a locațiilor respective. A. Breivik s-a
informat cu privire la școala de vară a Partidului Laburist
(aproape 600 de participanți).
3. Comportament antefaptic imediat
În ziua comiterii crimelor s-a pregătit pentru ambele
situații (aspect ce ar pune sub semnul
întrebării caracteristici ale ”spree murder”). S-a îmbrăcat
cu o uniformă de polițist, a încărcat mașina cu explozibil și
arme (pistol, armă automată și pușcă de asalt) și a plecat la
Oslo.
4.Mod de comitere a faptelor
Ajuns la locul stabilit anterior, a detonat bomba artizanală
și apoi a plecat; a luat feribotul spre insula (a ajuns după
aproximativ 2 ore). Ajuns pe insulă, a cerut tinerilor să se
adune în jurul său pentru a se face auzit mai bine ( le-a spus
că a venit să afle indicii despre explozia ce avusese loc în
urmă cu câteva ore la Oslo) după care a deschis focul. Zeci
de oameni au sărit în apă. După ce a deschis focul a început
să strige: "O să vă ucid pe toți! Vom muri cu toții". Trăgea
la întâmplare, întâi în cei de pe insulă și apoi în cei care
săriseră în apă. La venirea poliției s-a liniștit și s-a predat.
5.Comportament postfaptic
5.1. A colaborat cu poliția, cu personalul penitenciar și cu
comisia de expertiză; a recunoscut faptele susținându-și
conceptele extremiste;
5.2. A fost nemulțumit de concluziile primului raport de
expertiză medico-legală psihiatrică.
5.3. A acceptat verdictul. A fost condamnat la 10 ani
închisoare; pentru ”periculozitate” a fost închis în condiții
de izolare (având la dispoziție 3 camere: dormitor, camere
pentru televizor și pentru exerciții fizice). În penitenciar
are relații amiabile cu personalul, nemanifestându-se
agresiv; încearcă să difuzeze ideile sale; s-a înscris într-un
partid neonazist. Nu i s-a permis învoire pentru mama sa.
Are la dispoziție mașină de scris electrică. Nu are acces la
internet.
5.4. A dat în judecată statul norvegian pentru rele
tratamente (ex. nu i s-au acordat destule compensații
pentru faptul că este închis la izolare, comunică cu
vizitatorii prin ”geam”, nu are termos pentru cafea caldă,
nu are destul spațiu de plimbare, jocurile PC puse la
dispoziție sunt sub nivelul său etc.). Curtea a respins
solicitările (exceptând faptul că i s-a permis să primească
44
vizite mai multe din partea personalului penitenciarului
pentru a sta de vorbă). A. Breivik a sesizat Curtea
Drepturilor Omului și pentru unele dintre cereri a avut
câștig de cauză.
5.5. În vederea efectuării celei de a doua experize, a fost
monitorizat (inclusiv video) timp de trei săptămîni;
personalul care l-a monitorizat (inclusiv psiholog, medici
generaliști) și casetele video nu au evidențiat
comportament psihotic.
V. A I I - a E X P E RT I Z Ă M E D I C O - L E G A L Ă
PSIHIATRICĂ
1. Comisia Medico- Legală a înaintat observații la raportul
efectuat anterior, dintre care cele mai importante sunt:
premizele asumate de către experți, privind criteriile ICD-
10 sunt insuficient susținute și nu s-a luat în discuție
tulburarea de personalitate, nu au fost obținute informații
complete privind perioadele ”copilărie, adolescență și
vârsta adultă și anii în care a trăit un adult cu mama sa”;
comisia subliniază că apare necesară ”o evaluare a
semnificației discrepanței dintre funcționarea socială
descrisă în contextul observării și reacțiile emoționale pe
care le manifestă față de acțiunile” sale. Comisia
subliniază, de asemenea necesitatea evaluării
comportamentului în perioada de custodie … ” Cazul
actual a demonstrat că reprezintă ”provocări neobișnuite
de diagnostic în psihiatrie”. … ”posibilă concluzie fals
negativă”, existînd posibilitatea ca examinatul să-și fi
”adaptat declarațiile la ceea ce el a găsit cel mai bine
servit. Aceasta se referă în special la descrierea sa a
organizației Cavalerii Templieri. În faza timpurie a
investigației, el a dat o minunată relatare despre presupusa
organizație și despre propria sa poziție în ea”.
2. Experții au stabilit strategia de expertizare: observare
video și prin intermediul personalului penitenciar,
consfătuiri cu medicii și psihologii penitenciarului,
reevaluarea documentelor avute la dispoziția, îndeplinirea
cerințelor privind completarea informațiilor privind cursa
existențială a examinatului, examinări clinice psihiatrice
seriate, discuții cu examinatul privind convingerile /
concepțiile sale, aplicarea de scale clinice și teste
psihologice adecvate ca SCID II, chestionarul Minessota,
test PANSS etc. Experții nu au constatat la examinări și nu
au delimitat, pentru ziua comiterii, crimelor simptome cu
caracter psihotic.
3. Experții au demontat aprecierile de idei expansive, de
mărire demonstrând că referirile din raportul anterior nu
sunt corect interpretate (lămuresc ”nedumeririle” privind
tema Cavalerilor Templieri, masoneria, fluctuațiile
financiare, caracteristicile exprimărilor ”naționaliste
extreme” etc.). Experții subliniază coerența acțiunilor,
bine etapizate și organizate.
4. În ceea ce privește ”neologismele” experții precizează:
că limba norvegiană este flexibilă, alăturarea de cuvinte
pentru a da alt înțeles este frecventă și dacă aceste noi
cuvinte vor fi folosite de mai multe personae vor intra în
vocabularul obișnuit; ” Anumite declarații pe care le-a
făcut / scrise pot fi interpretate ca niște iluzii grandioase,
însă el le poate explica mai târziu, iar modul său de a spune
lucrurile (formulările de vârf) exprimă mai mult
personalitatea sa decât spectrul psihotic. …. Nu există
neologisme … dar el a pus împreună cuvintele existente
(de la Templieri, Ordin Masonic, Justiție), care îi oferă
semnificație, dar acest lucru nu poate fi văzut pe un
neologism. Unele așa-numite neologisme, așa cum au

subliniat experții, pot fi căutate pe Internet. Nu a prezentat
nici un fel de "neologism” în cursul examinării. Se
apreciază că nu are tulburări de gîndire, ”cu excepția
faptului că are o ideologie extrem de extremă”.
5. ”Nu se observă semne de simptome negative … apare
cu lipsa de empatie. … are o rigiditate”, dar apare mai mult
pendinte de ”personalitatea sa decât rigiditatea descrisă la
persoanele cu schizofrenie”.
6. Testele psihologice și scalele clinice nu evidențiază
itemi caracteristici unor tulburări psihotice dar se
delimitează trăsăturile tulburării de personalitate de tip
antisocial (ceea ce explică deficitul empatic) și de tip
narcisistic (asociere frecvent întâlnită la persoanele cu
potential agresiv).
7. A fost efectuat diagnosticul diferențial cu patologia din
spectrul psihotic și cel al tulburărilor de personalitate.
8. Experții au concluzionat că Anders Breivik nu a
prezentat în ziua comiterii crimelor și în perioada
examinărilor simptomatologie psihotică; prezintă
tulburare de personalitate antisocială și narcisistică.
CONCLUZII
1.Personal, consider că este vorba de o tulburare de
personalitate conturată antisocial, narcisistic și paranoid.
2.Conceptele exprimate și acțiunile sale caracterizează
extremismul terorist (”terorism creștin”) ceea ce nu
implică patologie psihotică (ar însemna că toți extremiștii
fanatici care comit acte teroriste ar trebui să fie etichetați
ca psihotici).
3.Diagnosticul diferențial a fost dificil și datorită modului
de expertizare (inadvertențe, contradicții, alegeri
neadecvate a investigațiilor, deficit de informații privind
cursa existențială etc.).
4.Se constată necesitatea ca pentru fiecare caz în parte,
expertul să se informeze și asupra problemelor tangente;
cunoșterea psihopatologiei nu este suficientă în cazuri
complexe cu implicații juridice (a se vedea introducerea
detaliată a acestui articol).
5.Din perspectiva jurisprudenței românești, opiniez că
Anders Breivik a acționat cu discernământ (a avut
capacitate psihică de apreciere critică asupra conținutului
și consecințelor social – negative ale faptelor sale).
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judiciară”, în Diana Bulgaru – Iliescu, Gabriela Costea, Alexandra
Enache, Liviu Oprea, Valentin Gheorghiu, Vasile Astărăstoaie: Expertiza
medico-legală psihiatrică – abordare interdisciplinară, Ed. Timpul, Iași –
2013, pg. 163-180;
28. Dan Prelipceanu, ”Alcoolismul”, în Diana Bulgaru – Iliescu,
Gabriela Costea, Alexandra Enache, Liviu Oprea, Valentin Gheorghiu,
Vasile Astărăstoaie: Expertiza medico-legală psihiatrică – abordare
interdisciplinară, Ed. Timpul, Iași – 2013, pg. 181-186;
29. Gabriela Costea, ”Imaginația în materia expertizei medico-legale
psihiatrice. Simularea”, în Diana Bulgaru – Iliescu, Gabriela Costea,
Alexandra Enache, Liviu Oprea, Valentin Gheorghiu, Vasile
Astărăstoaie: Expertiza medico-legală psihiatrică – abordare
interdisciplinară, Ed. Timpul, Iași – 2013, pg. 253-282;
30. Gabriela Costea, Funcția volitivă în material expertizei medico-
legale psihiatrice; competența psihică”, în Diana Bulgaru – Iliescu,
Gabriela Costea, Alexandra Enache, Liviu Oprea, Valentin Gheorghiu,
Vasile Astărăstoaie: Expertiza medico-legală psihiatrică – abordare
interdisciplinară, Ed. Timpul, Iași – 2013, pg. 283-300;
31. Gabriela Costea, George Talău, ”Procesarea taxonomică psihiatrică
și managementul obținerii informațiilor necesare ți a investigațiilor /
examinărilor interdișciplinare în practica de expertiză medico-legală
psihiatrică”, ”, în Diana Bulgaru – Iliescu, Gabriela Costea, Alexandra
Enache, Liviu Oprea, Valentin Gheorghiu, Vasile Astărăstoaie: Expertiza
medico-legală psihiatrică – abordare interdisciplinară, Ed. Timpul, Iași –
2013, pg. 339-364;
32. Gabriela Costea, ”Perspectiva sociologică și criminological în
psihiatria medico-legală”, 18. Gabriela Costea, ”Abordarea conceptuală
în psihiatria medico-legală”, în Diana Bulgaru – Iliescu, Gabriela
Costea, Alexandra Enache, Liviu Oprea, Valentin Gheorghiu, Vasile
Astărăstoaie: Expertiza medico-legală psihiatrică – abordare
interdisciplinară, Ed. Timpul, Iași – 2013, pg. 29-68;
45
Gabriela Costea: ABB – criminalul morvegian. Psihoză versus psihopatie - analiză medico-legală psihiatrică

33. Costea S. Gabriela, Dragomirescu Simona, ”Raportul de expertiza Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim,
medicolegală psihiatrica în statele europene”, lucrare prezentată la Germany 2005, p.136-144;.
Congresul Național de Medicină Legală, 20 – 23 Mai 2010, Bran, 47. http://www.document.no/2012/02/forensicpsychiatric-statement-
România; anders-behring-breivik; Meloy, J. R., & O'Toole, M. E. (2011). ...
34. Hans Joachim Salize, Harald Dreßing, sub. red., “Final Report of Psychiatric forensic report on Anders Breivik translated into English;
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35. David James, “Final Report of Research Project – Placement and by I Melle - ‎201;
Treatment of Mentally Ill Offenders – Legislation and Practice in EU
member states”, of the European Commission – Health and Consumer TABEL NR. 1 - TERMINOLOGIE FOLOSITA IN
Protection Directorate General”, sub red. Hans Joachim Salize & Harald PREVEDERILE LEGALE
Dreßing, Central Institute of Mental Health, Mannheim, Germany 2005,
p. 122-135; TERMINOLOGIE LEGALA
36. Hans Schanda, Göllersdorf - “Final Report of Research Project – AUSTRIA BOLI MINTALE, DEFICIENTA MINTALA,
Placement and Treatment of Mentally Ill Offenders – Legislation and MODIFICARE PROFUNDA A
Practice in EU member states”, of the European Commission – Health CONSTIINTEI, ALTE CONDITII MENTALE
and Consumer Protection Directorate General”, sub red. Hans Joachim ANORMALE, ANORMALITATE MENTALA
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim, BELGIA DEFICIENTA MINTALA, RETARDARE
Germany 2005, p. 91-98;. MINTALA, DEZECHILIBRU MENTAL
37. Pierre Lamothe, Frederic Meunier, “Final Report of Research Project SEVER, INSANITY
– Placement and Treatment of Mentally Ill Offenders – Legislation and DANEMARCA BOLI MINTALE, STATUS EGAL CU BOLI
Practice in EU member states”, of the European Commission – Health MINTALE, RETARDARE MINTALA
and Consumer Protection Directorate General”, sub red. Hans Joachim MODERATA SAU PROFUNDA,
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim, DEZVOLTARE NEADECVATA,
Germany 2005, p.145-150;. MODIFICARE SAU TULBURAREA A
ABILITATILOR MINTALE
38. Dermot Walsh, “Final Report of Research Project – Placement and
REGATUL UNIT TULBURARE MINTALA DEFINITA PRIN
Treatment of Mentally Ill Offenders – Legislation and Practice in EU
BOALA MINTALA (NEDEFINITA),
member states”, of the European Commission – Health and Consumer MODIFICARE MENTALA (CAND
Protection Directorate General”, sub red. Hans Joachim Salize & Harald TRATAMENTUL POSIBIL ARE SANSE DE
Dreßing, Central Institute of Mental Health, Mannheim, Germany 2005, SUCCES), MODIFICARE MENTALA
p.167-175;. SEVERA (CAND TRATAMENTUL POSIBIL
39. Helena Silfverhielm, “Final Report of Research Project – Placement NU ARE SANSE DE SUCCES), TULBURARE
and Treatment of Mentally Ill Offenders – Legislation and Practice in DE PERSONALITATE (CAND
EU member states”, of the European Commission – Health and TRATAMENTUL POSIBIL ARE SANSE DE
Consumer Protection Directorate General”, sub red. Hans Joachim SUCCES), ALTE DISABILITATI MINATLE
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim, FINLANDA NEBUNIE, ABSENTA SENILA A
Germany 2005, p.215-224;. INTELEGERII, CONDITII SIMILARE,
40. Catharina H. de Kogel, “Final Report of Research Project – BOALA MINTALA
Placement and Treatment of Mentally Ill Offenders – Legislation and FRANTA TULBURARE MINTALA CU
Practice in EU member states”, of the European Commission – Health MODIFICAREA DISCERNAMANTULUI SI
A CAPACITATII DE AUTOCONTROL
and Consumer Protection Directorate General”, sub red. Hans Joachim
GERMANIA TULBURARE MINTALA, TULBURARE
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim,
PROFUNDA A CONSTIINTEI,
Germany 2005, p. 189-196; ANORMALITATE SEVERA MENTALA,
41. Francisco Torres Gonzalez, “Final Report of Research Project – DISABILIITATE INTELECTUALA
Placement and Treatment of Mentally Ill Offenders – Legislation and GRECIA PERTURBARE MORBIDA A FUNCTIILOR
Practice in EU member states”, of the European Commission – Health INTELECTUALE SAU PERTURBARE A
and Consumer Protection Directorate General”, sub red. Hans Joachim CONSTIINTEI
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim, IRLANDA BOALA MINTALA, HANDICAP MINATAL,
Germany 2005, p.207-214;. DEMENTE SAU ALTE BOLI MINTALE
42. Paul Cosyns, Roel Verellen, – “Final Report of Research Project – ITALIA DEFECT MINTAL, HANDICAP MINTAL,
Placement and Treatment of Mentally Ill Offenders – Legislation and DEMENTA SAU ORICE BOALA MINTALA
Practice in EU member states”, of the European Commission – Health LUXEMBURG TULBURARE MINTALA CU
and Consumer Protection Directorate General”, sub red. Hans Joachim MODIFICAREA DISCERNAMANTULUI SI
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim, A CAPACITATII DE AUTOCONTROL,
Germany 2005, p.99-104;. IMPOSIBILITATE PUTERNICA DE
43. Michael Osterheider, Bernd Dimmek, “Final Report of Research STAPANIRE, TULBURARI PSIHICE
Project – Placement and Treatment of Mentally Ill Offenders – SEVERE CU PERICULOZITATE
Legislation and Practice in EU member states”, of the European OLANDA DEFICIENTE DE DEZVOLTARE (PSIHICA),
TULBURARI PATOLOGICE MINTALE
Commission – Health and Consumer Protection Directorate General”,
PORTUGALIA ANORMALITATE PSIHICA
sub red. Hans Joachim Salize & Harald Dreßing, Central Institute of
SPANIA ANOMALII PSIHICE, ALTERARE PSIHICA,
Mental Health, Mannheim, Germany 2005, p. 152-159;
INTOXICATII, TULBURARI
44. Angelo Fioritti, Rimini, “Final Report of Research Project – PERCEPTUALE
Placement and Treatment of Mentally Ill Offenders – Legislation and SUEDIA TULBURARI MINTALE GRAVE,
Practice in EU member states”, of the European Commission – Health TULBURARI MINTALE, TULBURARI
and Consumer Protection Directorate General”, sub red. Hans Joachim SEVERE DE PERSONALITATE
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim, NORVEGIA BOALĂ PSIHICĂ GRAVĂ, STAREA DE
Germany 2005, p. 176-183; CON?TIIN? Ă, DEBILITATEA MINTALĂ
45. Peter Kramp, “Final Report of Research Project – Placement and ROMÂNIA DISCERNĂMÂNT, PERICOL SOCIAL,
Treatment of Mentally Ill Offenders – Legislation and ALIENARE MINTALĂ, DEBILITATE
Practice in EU member states”, of the European Commission – Health MINTALĂ
and Consumer Protection Directorate General”, sub red. Hans Joachim
Salize & Harald Dreßing, Central Institute of Mental Health, Mannheim,
Germany 2005, p.105-121;.
46. Riitakertuu Kaltialla-Heino, “Final Report of Research Project –
Placement and Treatment of Mentally Ill Offenders – Legislation and
Practice in EU member states”, of the European Commission – Health
and Consumer Protection Directorate General”, sub red. Hans Joachim

46
 Romanian Journal of Psychiatry, vol. XIX, No.2, 2017

TABEL NR. 2 INSTITUȚIILE CARE DISPUN EXPERTIZE MEDICO-LEGALE PSIHIATRICE

INSTANTE AGENTII NATIONALE APARARE

AUSTRIA X
BELGIA X
DANEMARCA X
REGATUL UNIT X
FINLANDA AUTORITATEA PENTRU AFACERI MEDICO-LEGALE
FRANTA X
GERMANIA X
GRECIA X
IRLANDA X
ITALIA X
LUXEMBURG X
OLANDA X
PORTUGALIA INSTITUTUL NATIONAL DE MEDICINA LEGALA
SPANIA X
SUEDIA BORDUL NATIONAL DE PSIHIATRIE

TABEL NR. 3 – CALITATEA EXPERȚILOR

1 2 MAI MULT NU SE PSIHIATRU ORICE ALTI NU SE

DECAT 2 PRECIZEAZA NR. MEDIC DEFINESTE
CALITATEA
EXPERTULUI
AUSTRIA X X
BELGIA X
DANEMARCA X X
REGATUL X X X
UNIT
FINLANDA X X
FRANTA X X x
GERMANIA X X
GRECIA X X
IRLANDA X X
ITALIA X X
LUXEMBURG X X
OLANDA X x
PORTUGALIA X X
SPANIA X X
SUEDIA X X X x
NOTA
NORVEGIA EXPERTIZA ESTE DISPUSĂ DE CĂTRE INSTANTĂ ; NR. DE EXPERTI (MEDICI PSIHIATRI)
ESTE PRECIZAT DE CĂTRE INSTANTĂ ; VALIDAREA (SAU NU) CONCLUZIILOR
RAPOARTELOR ESTE FĂCUTĂ DE CĂTRE CONSILIUL REGAL DE MEDICINĂ LEGALĂ
(COMISIA MEDICO-LEGALĂ). MEDICII PSIHIATRII MENTIONEAZĂ DACĂ AU MAI
EFECTUAT SAU NU EXPERTIZE SIMILARE.
ROMÂNIA EXPERTIZA POATE FI DISPUSĂ DE CĂTRE INSTANTE, PARCHETE, POLITII (INCLUSIV
SECTII COMUNALE ETC.). NR. DE EXPERTI ESTE ”3” (COMISIE FORMATĂ DIN 2 PSIHIATRI
SI UN MEDIC LEGIST). MEDICII PSIHIATRI DIN COMISIE DEVIN, AUTOMAT, EXPERTI
OFICIALI PENTRU FIECARE CAZ DE EXPERTIZĂ ÎN PARTE,
FRANTA EXPERTII TREBUIE SĂ AIBĂ COMPETENTĂ ÎN STIINTE COMPORTAMENTALE.
OLANDA SUNT PREFERATI PSIHOLOGII SPECIALIZATI ÎN PSIHOLOGIA MEDICO-LEGALĂ
ÎN TOATE TĂRILE SUNT PREFERATI MEDICII PSIHIATRI

47
REVIEW ARTICLES
GENETICS OF ALCOHOL USE DISORDER
Maria Bonea1, Ioana V. Micluţia2
Abstract:Contrary to the stigmatizing perception, alcohol
dependence is not a mark of moral decay, but the result of
combining environmental, social, cultural and especially
biological factors, family studies finding that about 50% of
the risk is due to heredity. Genetic linkage and association
studies have failed to identify significant risk alleles,
except for the alcohol-metabolizing enzyme genes. Thus, a
INTRODUCTION
According to the World Health Organization
(WHO), harmful alcohol consumption is responsible for
5.9% of the global mortality, with a 3-4 times higher risk of
premature death for alcoholics compared to the general
population. The association with behavioral and
psychiatric disorders is well known, alcohol dependence
has become one of the most important public health
problems through its social and economic impact and
strong functional and quality of life impairment, even at a
young age. (1)
It is estimated that in developed countries, up to 80% of
male and 60% of female adults use alcohol at some time in
their lives, the prevalence of dependence for men reaching,
according to some studies, even 10%. (2)
Current diagnostic criteria, established by the
International Classification of Diseases, 10th edition (ICD-
10) and the Diagnostic and Statistical Manual of Mental
Disorders, 5th edition (DSM-5), do not match perfectly on
this topic. If DSM-IV-TR describes two distinct disorders,
alcohol abuse and dependence, DSM-5 integrates these
two entities into a single one Alcohol Use Disorder (AUD).
(3) At the more severe end of the spectrum, the dependence
implies tolerance, withdrawal, loss of control, compulsion
("craving") to drink daily or almost daily, despite
significant disability. The disorder may be
underdiagnosed, some studies revealing that only a quarter
of addicts receive treatment. (4) By applying DSM-5
criteria, in the US, 36% of men and 22.7% of women
develop AUD during their lifetime, in the younger
population, gender differences have narrowed. (5)
In the “Alcohol related disorders” chapter, ICD-
10 differentiates between harmful use (assuming physical
or mental impairment) and alcohol dependence, that
requires three out of six positive criteria: strong desire or
compulsion to drink, difficulties in avoiding initial use, in
discontinuing and controlling the consumed quantity,
withdrawal or alcohol use to avoid its symptoms,
tolerance, neglecting other activities / interests to obtain,
use or recover after consumption, continued use despite
physical, psychological or cognitive problems. (6)
Besides several types of genetic studies, another
1
Psychiatry Resident, PhD student, Children's Emergency Hospital, Cluj Napoca. Correspondence: Bonea Maria, Psychiatry Clinic, Victor Babeș Street
no. 43, Cluj-Napoca, România. E-mail: Bonea.Maria@umfcluj.ro; Phone: 004 0727 187 292
2
Professor Doctor, Head of Psychiatry Department, University of Medicine and Pharmacy "Iuliu Hațieganu" Cluj-Napoca
Received January 29, 2017, Revised February 29, 2017, Accepted March 17, 2017
48
new approach was needed - genome wide association
studies (GWAS) that do not depend on a pre-existing
hypothesis and highlighted new polymorphisms
associated with susceptibility to alcoholism. A review of
family, twin, linkage, candidate genes and GWAS will be
briefly presented.
Keywords:alcoholism, gene, polymorphism, genetic study
argument for the role of genetics in the development of
alcoholism are laboratory animals genetically
manipulated to present features such as the preference for
alcohol, sensitivity to the sedative effects or withdrawal
symptoms. (7)
FAMILY AND TWIN STUDIES
Cognitive tests applied during functional MRI
revealed inappropriate activation of long neural pathways
that connect temporo-parietal regions to prefrontal areas.
These brain disturbances occur in families with a strong
history of alcohol dependence, supporting a biological
basis, genetically determined. The impairment of
cognitive functions and work memory required to resolve
conflicts generates the disinhibited, even antisocial
behavior. (8)
Twin studies report that 50-70% of the risk of
developing an AUD is given by genetic factors. The
strongest association was with the reducing risk genotype,
the allele ALDH2 * 2 (the gene encoding the
mitochondrial hepatic enzyme aldehyde
dehydrogenase).The polymorphism, common in Asians,
but rare in Europeans, leads to altered alcohol metabolism
with the development of facial erythema, tachycardia,
sweating and gastrointestinal symptoms, creating
aversion. (9)
LINKAGE STUDIES
The COGA study (Collaborative Study on the
Genetics of Alcoholism) identified regions of interest on
chromosomes 1, 2, 10, 13. (10) Depending on the
components of alcoholism, regions on chromosomes 1
and 11 were associated with the initial response to
alcohol, the age of onset with areas on chromosome 9,
while a maximum alcohol use, with regions on
chromosomes 12 and 18. Signals from the chromosomes
1, 6 and 22 were correlated with tolerance, while the
severity of the withdrawal was linked to a region on
chromosome 2. (11)Likewise, regions encoding the
structure of the Gamma-Aminobutyric Acid Type A
Receptor, Alpha2 Subunit (GABRA2), located on
chromosome 4 were correlated with addictions in

general.(12) In the same way, the muscarinic
acetylcholine M2 (CHRM2) genes, located on
chromosome 7q were found to affect cognitive functions,
depressive symptoms and the development of alcohol
dependence.(13, 14)
ASSOCIATION (CANDIDATE GENE) STUDIES
Association studies, that test candidate genes in
regions discovered through linkage studies, confirmed the
protective effect of Alcohol Dehydrogenase 1B (Class I),
Beta Polypeptide alleles ADH1B*2 (found in Asian
populations) and ADH1B*3 (more specific for African
Americans) and also of the Alcohol Dehydrogenase 1C
(Class I), Gamma Polypeptide allele ADH1C*2, which
stimulates the metabolism of alcohol to acetaldehyde. A
similar lower risk of dependence was associated with the
Aldehyde Dehydrogenase 2 Family (Mitochondrial)
allele, ALDH2*2 (that hampers acetaldehyde
metabolism). (15)
Most of the known neurotransmitters play a role in the
development of addiction. The polymorphism of the
Ankyrin Repeat And Kinase Domain Containing 1 of
the D2 dopamine receptor (DRD2/ANKK1), involved in
reward pathways that activates pleasure-generating
behaviors (consumption of carbohydrates and fats, sexual
activity) and also the survival instinct, was correlated with
alcohol preference. (16)
Polymorphisms of the genes encoding type A
GABA receptor (GABRA2, the most widespread class of
cerebral inhibitory receptors that influences the subjective
response to ethanol) and of the type B GABA receptor
correlate with alcohol dependence. (17,18). Other studies
refute the relationship between GABAergic system genes
and alcoholism, limiting it only to specific situations such
as poly substance abuse or a particularly strong family
history. (19)
Neuropeptide Y gene (NPY), with the G1258A
single nucleotide polymorphism (SNP) and the NPY Pro7
allele modulates risk of alcohol dependence in the central
amygdala by translating negative emotional states in
anxiety generated behavior. (20,21,22). In the same way,
the polymorphism of the corticotropin releasing factor 1
receptor gene (CRF1-R) influences the anxious
phenotype that leads to excessive ethanol consumption.
(23)
In the cholinergic system, the beta 2 subunit of
the nicotinic cholinergic receptor (CHRNB2) was
associated with the response to alcohol and nicotine. (24)
Imaging studies and animal models support the
involvement of serotonin receptor and transporter.
Alcohol and nicotine co-dependence, but also attention-
deficit hyperactivity disorder (ADHD) appear to be
influenced by genetic variants of the Importin 11 region of
the 5-Hydroxytryptamine Receptor 1A (IPO11-HTR1A).
(25, 26) Changes in the presynaptic 1B serotonin
autoreceptor gene may determine the susceptibility to
alcohol dependence, and also to cocaine and heroin abuse,
some studies suggesting that the polymorphisms HTR1B
A-161 could represent a genetic marker for alcoholism.
(27, 28)
The gene for the serotonin receptor 4 (HTR4), located in
the limbic system, specifically in the hippocampus,
involved in the development of depression by generating
anhedonia, could have a role in the pathogenesis of
alcohol dependence. (29, 30) The polymorphism of the
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
Solute Carrier Family 6 Member 4 gene promoter region
(SLC6A4), on chromosome 17, encoding the serotonin
transporter, has been evaluated in multiple studies
regarding its association with alcohol dependence, but a
meta-analysis concluded that this relationship does not
exist. (31) On the other hand, in the case of alcoholism
comorbid with depression, homozygous carriers of the S
allele of the serotonin-transporter-linked polymorphic
region (5HTTLPR) have an increased risk. (32)
Lastly, glutamatergic system genes seem to play
a role in addiction development. Thus the N-methyl-D-
aspartate (NMDA) subunit of the glutamate receptor 2B
(Glu2B) is overexpressed in the hippocampus after
chronic exposure to ethanol. (33) SNPs of the
metabotropic glutamate receptor 3 gene (GRM3)
modulates the prefrontal cortex activity in alcoholic
patients, influencing the executive functions. (34)
GENOME WIDE ASSOCIATION STUDIES (GWAS)
Genome-Wide Association Studies (GWAS)
conducted on samples of thousands of alcohol addicted
patients, is a more recent approach, different from genetic
linkage studies, which can discover unknown alleles
involved in the development of a certain pathology. The
criterion for statistical significance in this type of study is
very restrictive (p5x10- ), so only a few genes have been
8
reported to be associated with alcoholism. Unlike
association studies, GWAS do not require the involvement
of a particular gene hypothesis that should be tested. (34).
GWAS does not search for a specific gene,
instead millions of SNPs across the entire genome are
analysed. The first positive study of this kind on
alcoholism was published in 2009 by Treutlein et al, that
identified two new loci on chromosome 2q35, near the
gene for the peroxisomal trans-2-enozil-CoA reductase
(PECR, the key enzyme of fatty acid metabolism,
correlated with depression and with P300 response
amplitude, related to decision making). (35, 36)
Most GWAS have identified risk polymorphisms
of ADH and ALDH genes, others, which studied the
comorbidity with nicotine addiction, frequently
associated, found SNPs near the Microtubule Affinity
Regulating Kinase 1 gene (MARK1, that influences the
migration of neurons in the hippocampus) and near the
diethylazodicarboxylate Bis(oxazoline) helicase 6
(DEAD-Box Helicase 6, DDX6, involved in cell
development and differentiation). (37, 38, 39)
Chen et al. revealed that the ankyrin repeat
domain-containing protein 7 gene located on
chromosome 7q31 (ANKRD7, which influence the
functioning of the cerebellum) and cytokine-like1 gene on
chromosome 14p16 (CYTL1, correlated with bipolar
disorder and schizophrenia) could play an important role
in risk developing alcohol dependence. (40)
WHOLE GENOME SEQUENCING
Genomics is constantly developing techniques
for sequencing the entire genome, with the cheaper
version of the whole exome sequencing (WES) becoming
increasingly more affordable. In this way, rare recessive
mutations can be identified in exonic regions (areas that
encode proteins). These techniques found point mutations
in autism spectrum, affective and psychotic disorders, so
favorable results in connection to addiction could be
expected. (41)
49
Maria Bonea, Ioana V. Micluţia: Genetics of Alcohol Use Disorder
ABBREVIATIONS
GWAS – Genome Wide Association Studies
WHO - World Health Organization
ICD-10 - International Classification of Diseases, 10th
edition
DSM - Diagnostic and Statistical Manual of Mental
Disorders
AUD - Alcohol Use Disorder
ALDH - aldehyde dehydrogenase
COGA - Collaborative Study on the Genetics of
Alcoholism
GABRA2 - Gamma-Aminobutyric Acid Type A Receptor
Alpha2 Subunit
CHRM2 - Cholinergic Receptor Muscarinic 2
ADH1B - Alcohol Dehydrogenase 1B (Class I), Beta
Polypeptide
ADH1C - Alcohol Dehydrogenase 1C (Class I), Gamma
Polypeptide
ALDH2 - Aldehyde Dehydrogenase 2 Family
(Mitochondrial)
DRD2/ANKK1 - Ankyrin Repeat And Kinase Domain
Containing 1 of the D2 dopamine receptor
NPY - Neuropeptide Y
SNP - Single Nucleotide Polymorphism
CRF1-R – Corticotropin Releasing actor 1 Receptor
CHRNB2 - Cholinergic Receptor Nicotinic Beta 2
Subunit
ADHD - attention-deficit hyperactivity disorder
IPO11-HTR1A - Importin 11 region of the 5-
Hydroxytryptamine Receptor 1A
HTR1B A - 5-Hydroxytryptamine Receptor 1B
HTR4 - 5-Hydroxytryptamine Receptor 4
SLC6A4 - Solute Carrier Family 6 Member 4
5HTTLPR - Serotonin-transporter-linked polymorphic
region
NMDA - N-methyl-D-aspartate
Glu2B - Glutamate Receptor 2B
GRM3 - Glutamate Metabotropic Receptor 3
PECR - Peroxisomal Trans-2-Enoyl-CoA Reductase
MARK1 - Microtubule Affinity Regulating Kinase 1
DDX6 - DEAD-Box Helicase 6 (diethylazodicarboxylate
Bis(oxazoline) helicase 6)
ANKRD7 - Ankyrin Repeat Domain 7
CYTL1 - Cytokine Like 1
WES - Whole Exome Sequencing
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51
REVIEW ARTICLES
PSYCHOSOCIAL FACTORS INFLUENCING
ASPERGER DISORDER
Mihai Gabriel Alin Șuiu Apostol1, Oana Boantă2, Mihnea Manea3, Iuliana Dobrescu4
Abstract:
Asperger Disorder is influenced in its evolution by social
factors such as: Anxiety, Self-esteem and Aggression.
Anxiety can manifest itself in different ways based on the
life experience of the individual. Recent studies have
shown that cognitive behavioral therapy based on social
skills represents an efficient treatment in persons with
Asperger Disorder. Strong Self-esteem in childhood is a
protective factor against family demands, social pressure
and some defiant behaviors in the next stages of life.
Children with high Self-esteem present safety and
Anxiety, Self-esteem and Aggression are
psychosocial factors affected and consequently influence
Asperger Disorder. There are discussions about the
distinction between anxiety as a comorbidity and anxiety
as a base symptom in Autism Spectrum Disorder. The lack
of social skills in children with Asperger Disorder leads to
anxiety, frustration, anger crisis which affect the self-
esteem. Aggression as a challenging behavior occurs in
children with Asperger Disorder as a way to communicate
the needs; a consequence of poor expressive language.
ANXIETY
It is a natural reaction of the body to danger,
manifested by being afraid, fear, neurodegenerative
disorders (palpitations, polipnee, sweating).
Anxiety can manifest in different ways based on the life
experience of the individual:
-phobic anxiety disorders: -agoraphobia
-social phobias
-panick attacks;
-obsessive compulsive disorders;
-adjustment disorders;
-conversion disorders;
-somatization disorders;
Among adolescents with autism spectrum disorder, there
is an increased frequency of anxiety and depression
compared to the general population, the prevalence rate of
anxiety ranging from 13.6% (1) to 84% (2). It is difficult to
distinguish between anxiety as comorbidity and anxiety as
a base symptom in Autism Spectrum Disorder. For
children with Autism Spectrum Disorder, although there is
an increased risk of developing a form of anxiety, not all
children with autism show also anxiety, and the ones who
show it exhibit various forms along the way.
There is a real dispute around this controversy.
1
MD PhD student Carol Davila University of Medicine and Pharmacy, Bucharest
2
MD PhD student, C.F.2 Clinical Hospital, Bucharest
3
MD PhD, Senior Lecturer, Psychiatry and Psychology Department, Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine,
Bucharest
4
MD PhD, Primary Doctor in Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Department “Prof. Dr. Al. Obregia” Psychiatry Hospital
Professor of Child and Adolescent Psychiatry Department, University of Medicine and Pharmacy “Carol Davila” Bucharest
Received January 29, 2017, Revised February 29, 2017, Accepted March 17, 2017
52
confidence in overcoming some existantial obstacles and
broader personal skills in school; and the ones with low
Self-esteem have an inferiority complex in relation with
other children and are distrustful in their academic
possibilities. Aggression is a form of behavior oriented in
a destructive way, being able to cause matierla, moral or
psychological damage. In subjects with Asperger
Disorder, provocative behaviors including physical
aggression, appear as a necessity to communicate the
needs in the absence of expressive language.
Key words: aggression, anxiety, self-esteem, Asperger
Although anxiety is seen in a very high percentage in the
symptoms of children with Asperger Disorder, anxiety
disorders are less diagnosed (3). Sometimes
aggressiveness arising from an anxious behavior may be
perceived as a behavior associated with Asperger
Disorder (4), differentiation being very difficult,
especially when the anxiety symptoms are long lasting.
Cognitive deficits may prevent anxiety Disorder with
substantial cognitive components like social phobia (2).
Children with Asperger Disorder who attend normal
schools can be more exposed to stress factors versus
others, contributing to the development and maintenance
of anxiety.
Ashburner, J., Ziviani, J., and Rodger, S. (2010) (5)
suggested the following stress factors related to school:
-the complexity of the schedule and of the curriculum
area;
-frequent changes in their limited interests;
-lack of order and regularity in school activities;
-lack of relational flexibility;
-relational vulnerability (possibility of aggression or
social exclusion).
There are more causes that can develop anxiety to the
children with Asperger Disorder:
-parents with autistic children are prone to anxiety,
possibly symptoms can be transferred to the children
under various forms;
-hard to develop social relationships;
-marginalization of children with autism in social
relations;
-possibility of difficult communication.
The prevalence of anxiety disorder in children and
adolescents with Asperger Disorder was attributed to
neurobiological predispositions. The prefrontal cortex,
limbic system and serotonin are responsible both for:

-fear (6)
-anxiety (7)
-aggressivity (8)
-violence (9)
as well as for the etiology of autism spectrum.(10)
Neuropsychology studies of Autism have developed
several theories that try to make cognitive connections
between brain abnormalities and behavioral symptoms in
autism (11). The mind theory refers to the difficulties
people with autism have in planning and organizing
activities, in understanding other people's intentions and
desires (12). These theories have been applied to
understand autistic thinking in therapeutic intervention.
Discussions are at the possibility of applying the cognitive
behavioral therapy as treatment option for anxiety in
Asperger Disorder, having difficulties associated with the
emotions of identification and cognitive inflexibility (13)
or behavioral cognitive therapy lends itsfel well to the
intervention in Asperger Disorder due to the structured
systematic approach specific to the autistic thinking style.
Recent studies have shown that cognitive behavioral
therapy based on the social abilities represents an efficient
treatment for anxiety in people with Asperger Disorder
(14).
SELF-ESTEEM
Developing a strong self-esteem in childhood
represents a protective factor against the family demands,
social pressure and a few deviant behaviors in future
stages of life. Children with high self-esteem have safety,
confidence in overcoming existential obstacles and
broader personal skills in school. Conversely, those with
low self-esteem have an inferiority complex in
relationships with other children and are distrustful of
their academic possibilities.
Lack of social skills in children with Asperger
Disorder makes it hard for them to develop social
relationships and live the feeling of relational rejection.
Although social awareness is low in children with
Asperger Disorder, yet they realize they are different.
Social failures can lead to anxiety, frustration, anger crisis
which affect self-esteem.
Strategies can though be developed to increase self-
esteem with these children.
1.Tell the child that he is very precious, that he is capable
and endowed with special qualities.
2.Maintain constancy and safety in daily relations with the
children, creating an existential comfort zone.
3.Maintain the child's living space as a safety and friendly
zone.
4.Show a positive self-esteem and confidence in your
child's achievements.
5.Help him learn to use words and expressions through
which he can express his ideas and pleasant or unpleasant
feelings.
6.Inform people who come into close contact with your
child (family members, teachers, and friends) about the
techniques you are using to increase the self-esteem.
7.Seek to connect with other families who have children
with Asperger Disorder.
8.Encourage and congratulate each achievement of the
child with Asperger Disorder.
9.Teach the child with Asperger Disorder to build positive
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
strategies, to maintain his emotional balance by taking
deep breathes, thinking of pleasant things, avoiding
uncomfortable situations.
10.Constant correction of the behavior of the child with
Asperger Disorder may be perceived by him as a
criticism; therefore it must be agreed from the beginning
that this is only an attempt to change the negative behavior
with a positive one.
AGGRESSION
Aggression is a form of behavior that is oriented in a
destructive way, being able to cause material, moral or
psychological damage. Aggression should not be
confused with antisocial behavior, delinquency or
crime.
There is an aggression: physical, relational, outer
(hetero aggression), inner (auto aggression), active or
reactive (15).
In subjects with Asperger Disorder, due to
deficiencies in communication, provocative behaviors
including physical aggression, appear as a necessary to
communicate the needs in the absence of expressive
language.
Aggression in school is a maladaptive behavior,
leading to social exclusion and disciplinary actions.
Anger is a primordial emotion that can be expressed
through behaviors with aggression or violence.
McKinnie Burney, D., & Kromrey, J. (2001) proposed two
forms of anger:
-instrumental anger – a negative emotion that takes place
to obtain certain desired purposes
-reactive anger – immediate response to challenging
events.
Both can lead to aggression in the absence of control.
(16).
There are more strategies to reduce aggression in subjects
with Asperger Disorder:
1.Aggression manifested by the destruction of objects can
be transformed into a creative distruction (crushing carton
or aluminum cans for recycling, or transforming old
clothes into rags).
2.Building a menu of activities to reduce the stress level
(relaxation by listening to music, massage or soothing
bath)
3.Setting up a list of signs that can increase the stress level
the child should know to avoid (offensive words,
challenging gestures)
4.Trying to burn tension and anxiety with an uncontrolled
physical activity (sport, dance)
5.Discuss the consequences of aggressive acts.
REFERENCES:
1.Kim, JA., Szatmari, P., Bryson, SE., Streiner, DL. & Wilson, FJ. (2000)
The prevalence of anxiety and mood problems among children with
autism and Asperger syndrome. Autism, 4, 117-132
2.Muris P. et al (1998) Comorbid anxiety symptoms in children with
pervasive developmental disorders. Journal of Anxiety Disorders, 12 (4),
pp. 387-393
3.MacNeil, B.M.,Lopes,V.A.,&Minnes,P.M.(2009).Anxiety in children
and adolescents with autism spectrum disorders. Research in Autism
Spectrum Disorders 3(1), 1–21.
4.Tsai,L.Y.(2006).Diagnosis and treatment of anxiety disorders in
individuals with autism spectrum disorder
.InJ.G.M.G.Baron,G.Groden,&L.P.Lipsitt (Eds.), Stress and copingin
autism (pp. 388–440).NewYork: Oxford University Press
5.Ashburner,J.,Ziviani,J.,&Rodger,S.(2010).Surviving in the
mainstream: capacity of children with autism spectrum disorders to
53
Mihai Gabriel Alin Șuiu Apostol, Oana Boantă, Mihnea Manea, Iuliana Dobrescu: Psychosocial Factors Influencing
Asperger Disorder
perform academically and regulate their emotions and behavior at
school. Research in Autism Spectrum Disorders 4(1), 18–27.
6.Amaral, D.,Bauman,M.,&Schumann,C.(2003).The amygdala and
autism: implications from non-human primate studies.
Genes,Brain&Behavior 2(5), 295– 302
7.Kim, J.,&Gorman,J.(2005). The psychobiology of anxiety. Clinical
Neuroscience Research 4(5–6), 335–347.
8.Blair,R.J.R.(2010). Psychopathy, frustration, and reactive aggression
:the role of ventromedial prefrontal cortex. British Journal of
Psychology, 101(3), 383–399.
9.Siever,L.J.(2008).Neurobiology of aggression and violence. The
American Journal of Psychiatry 165(4), 429–442
10.Eigsti, I.-M.,&Shapiro,T.(2003).A systems neuroscience approach to
autism: biological, cognitive ,and clinical perspectives. Mental
Retardation and Developmental Disabilities Research Reviews 9(3),
205–215.
11.Happe, F. And Frith, U. (1996) The neuropsychology of autism.
Brain, 119, 1377-1400.
12.Pennington BF, Ozonoff S. Executive functions and developmental
54
psychopathology. Journal of Child Psychology and Psychiatry.
1996;37:51–87.
13.Chalfant, A.M., Rapee, R. and Carroll, L. (2007). Treating Anxiety
Disorders in Children with High Functioning Autism Spectrum
Disorders: A Controlled Trial, Journal of Autism and Developmental
Disorders, 37 (10), 1842-1857.
14.Weiss JA, Lunsky Y (2010) Group cognitive behaviour therapy for
adults with Asperger syndrome and anxiety or mood disorder: a case
series. Clin Psychol Psychother 17: 438-446.
15.Card, N. A., & Little, T. D. (2006). Proactive and reactive aggression
in childhood and adolescence: A meta-analysis of differential relations
with psychosocial adjustment. International Journal of Behavioral
Development, 30(5), 466-480.
16.McKinnie Burney,D.,&Kromrey,J.(2001). Initial development and
score validation of the adolescent anger rating scale. Educational and
Psychological Measurement 61(3), 446–460.
***
ORIGINAL ARTICLES

ELEVATED PLASMA FIBRINOGEN A POSSIBLE

BIOMARKER FOR PSYCHOLOGICAL DISTRESS
AND DEPRESSION
Traian Purnichi1, 4, Gabriela Puiu1, Ileana Marinescu2, Mihail C. Pîrlog3,
George Paraschiv4, Silvia Ristea4, Ruxandra Banu5, Ioana G. Pavel6, Mihai Bran7,
Lavinia Duică8, Ruxandra Grigoraș9, Valentin P. Matei10

Abstract: Depressive disorder represents the leading
cause of disability worldwide. An increasing body of
evidence suggests that patients presenting psychological
distress and depression show alterations in immunological
markers. The aim of our study was to observe the
correlation of fibrinogen as a potential biological marker
for psychological distress and depression. Data analyzed
in this paper refers to patients (N=100) included in a
prospective study conducted between 01 February-30
June 2016, males and females, age>18 years, recruited
from the patients whom presented for diverse para-clinical
evaluations in the outpatient clinic National Institute of
Gerontology and Geriatrics “Ana Aslan” (NIGG “Ana
Aslan”), Bucharest, Romania. Socio-demographic
information collected included: gender, age, marital
status, environmental origin, level of education, socio-
economic status. For all the participants of the study
fibrinogen was measured using a turbidimetry method.
Psychological distress and depressive symptoms were
evaluated using the Hospital Anxiety and Depression
Scale (HADS). From the total number of patients 64%
were female, with a mean age of 67 years, from the urban
area (92%), retired (80%).We found a mean value of
fibrinogen of 301.16 mg/dL (SD ± 63.20). At HADS-global
the patients presented a mean value of 15.9 (SD ± 7.31),
while at the HADS-D the mean value was 6.41 (SD ± 3.60).
Low statistically significant positive correlations between
fibrinogen and HADS-global ( rs(98)= .30, p= 0.0023) and
HADS-D (rs(98)=.36, p=0.0003) were found. Our study
results were consistent with the data literature reported
from previous studies showing a significant positive
correlation between psychological distress, depression
and fibrinogen. Also, we found higher levels of plasma
fibrinogen when we compared patients presenting
psychological distress with those without psychological
distress, even though the effect size was rather small.
Keywords: inflammation, emotional distress, fibrinogen,
major depressive disorder

Introduction neuroplasticity, inflammation and the circadian rhythm

Depression is a pervasive, complex and heterogeneous
disorder and represents the leading cause of disability
worldwide in terms of total years lost due to disability (1).
Current neurobiological theories are based on studies
investigating psychosocial stress and stress hormones,
neurotransmitters such as serotonin, norepinephrine,
dopamine, glutamate and gamma-aminobutyric acid
(GABA), altered neuro-circuitry function, altered
hypothalamic-pituitary-adrenal axis activity, neurotrophic
factors, and circadian rhythms (2). Several hypotheses
concerning the biologically based cause of depression
have been suggested over the years, including theories
revolving around monoamine neurotransmitters,
(3, 4, 5). Immunological mechanisms have been
implicated in the complex pathophysiology of depression
providing leads for further investigation of the hypothesis
considering that inflammation represents an important
etiological factor of depression. Despite the fact that the
exact disease mechanism is unknown, some previous
studies have shown that low-grade inflammation possibly
plays a role in the development of depression by
indicating an association between depression and
elevated inflammatory markers such as cytokines and
acute phase proteins (6, 7, 8). Also growing evidence
indicates that psychological distress is accompanied by
activation of the innate immune system, resulting in

1
MD, Hospital of Psychiatry „Prof Dr. Al. Obregia”, Bucharest
2
MD, PhD, University of Medicine and Pharmacy of Craiova, Faculty of Medicine, Department of Psychiatry; Clinical Hospital of Neuropsychiatry
Craiova.
3
PhD, Senior lecturer, University of Medicine and Pharmacy of Craiova, Department of Medical Sociology, Clinical Hospital of Neuropsychiatry
Craiova.
4
PhD student, University of Medicine in Craiova
5
MD, National Institute of Geriatrics in Bucharest
6
MD, Anima Clinic in Bucharest
7
MD, Colțea Hospital in Bucharest
8
MD, University Lucian Blaga Sibiu, Faculty of Medicine, Department of Psychiatry; „Gheorghe Preda” Psychiatry Hospital, Sibiu.
9
MD, Voila Psychiatric Hospital
10
MD, PhD, Senior lecturer, University of Medicine and Pharmacy „Carol Davila” Bucharest, Faculty of Medicine, Department of Psychiatry; Hospital
of Psychiatry „Prof Dr. Al. Obregia”, Bucharest
Received February 2, 2017, Revised February 29, 2017, Accepted March 17, 2017

55
Traian Purnichi, Gabriela Puiu, Ileana Marinescu, Mihail C. Pîrlog, George Paraschiv, Silvia Ristea, Ruxandra Banu,
Ioana G. Pavel, Mihai Bran, Lavinia Duică, Ruxandra Grigoraș, Valentin P. Matei: Elevated Plasma Fibrinogen a
Possible Biomarker for Psychological Distress and Depression
increased monocyte production of the pro-inflammatory
cytokines interleukin (IL)-6 and tumor necrosis factor
(TNF)-α and upregulation of the acute phase response
with increased synthesis of fibrinogen and C-reactive
protein (9). Fibrinogen exerts pro-coagulant function as a
precursor of fibrin in the coagulation cascade and as
cofactor for platelet aggregation and also a major acute
phase reactant synthesized by the liver during
inflammation (10). Jensen et al. showed that fibrinogen
stimulates synthesis of pro-inflammatory cytokines such
as interleukin-6 and tumor necrosis factor-α from
peripheral blood mononuclear cells, and hereby to
increase levels of pro-inflammatory cytokines (11). These
pro-inflammatory cytokines may activate the enzyme
indolamine-2,3-dioxygenase, which degrades the
precursor of serotonin, tryptophan (11). The decreased
concentrations of tryptophan determine a reduced
serotonin synthesis, which may lead to the development of
depression (12, 13). As fibrinogen is the precursor of
fibrin for production of thrombi, another possible
hypothesis could be that increased fibrinogen levels could
lead to increased risk of thrombus formation in vessels in
the brain, that secondary may lead to psychological
distress and depression. On the other hand another
possibility is that psychological distress and depression
could lead to increased fibrinogen levels. In several
studies increased levels of depressive symptoms, and
clinical depression, respectively, have been associated
with elevated fibrinogen (6, 14, 15, 16), although others
failed to find a significant association (17-21).
The aim of our study was to analyze if there is a correlation
between the inflammatory markers like fibrinogen and
depressive symptoms and if fibrinogen could be a
potential biological marker for psychological distress and
depression symptoms severity.
Material and methods
Data for present paper was obtained after an analysis of a
prospective study conducted between 01 February - 30
June 2016, on a sample comprised 101 adult participants,
males and females, aged over 18 years, recruited from the
patients whom presented for various para-clinical
evaluations in the outpatient clinic National Institute of
Gerontology and Geriatrics “Ana Aslan” (NIGG “Ana
Aslan”), Bucharest, Romania. Details of the study were
explained to every patient and a written informed consent
was obtained from all participants. The socio-
demographic data collected included: gender, age, marital
status, environmental origin, level of education, socio-
economic status. Data about family history, pathological
personal history, diagnosis of depressive disorder,
symptoms at onset, number of hospitalizations for
diagnosis of depressive disorder, previous antidepressant
treatment, association with psychotropic medication,
quality of response and side effects of medication, and
somatic comorbidities were also collected. For all patients
were recorded the following laboratory results: CBC,
GGT, glucose, total cholesterol, triglycerides, TSH,
fibrinogen, VSH, CRP and CRP-hs. All the participants
required to complete the Hospital Anxiety and Depression
56
Scale (HADS). HADS was designed to rate the symptom
level of depression (HADS-D) and anxiety (HADS-A)
and emotional distress in non- psychiatric populations
(22). There are two subscales, each of which has seven
items to rate depression (HADS-D) and anxiety (HADS-
A) on a 4-point Likert scale (0 = not at all, 3 = mostly;
range = 0–21 points). The recommended cut-off of ≥ 8
points to identify cases of elevated levels of anxiety and
depression symptoms had a sensivity and specificity of
both subscales consistently in the range of 0.70 to 0.90
(23). The approval for the HADS scale used was obtained.
This study was approved by the I.O.S.U.D. U.M.F.
Craiova ethical committee. We also had a collaboration
protocol with the outpatient clinic NIGG “Ana Aslan”.
For all participants in the study fibrinogen was measured
using a turbidimetry method (Coa-DATA 2001- a 2
channel coagulation analyzer from Dutch Diagnostics).
All measurements were done by laboratory technicians.
The normal fibrinogen range is considered to be 200 to
400 mg/dL, although normal value ranges may vary
slightly among different laboratories. Values above
400mg/dL were considered as a marker of inflammation.
In the final analysis entered only 100 participants because
the scale for one patient got lost.
Statistical analysis
All the statistical analysis was performed with SPSS
version 21 (SPSS Inc., Chicago Ill.) and included the
following tools: descriptive analysis, as the data were
skewed, not normally distributed, we needed to use the
Spearman correlation coefficient as a measure of the
correlation and Mann-Whitney U to determine effect size.
The correlation analyses express the strength of linkage or
co-occurrence between to variables in a single value
between -1 and +1. This value is called the correlation
coefficient. A correlation coefficient of 0 indicates that no
relationship between the variables exists at all. The
correlation coefficient “rule of thumb” interpretation is
the following: 0.90 to 1 (-0.90 to -1)= very high positive
(negative) correlation; 0.70 to 0.90 (-0.70 to -0.90)= high
positive (negative) correlation; 0.50 to 0.70 (-0.50 to -
0.70)= moderate positive (negative) correlation; 0.30 to
0.50 (-0.30 to -0.50 = low positive (negative) correlation;
0 to 0.30 (0 to -0.30)= negligible correlation (24). A
positive correlation coefficient indicates a positive
relationship between two variables (the larger variable
“A”, the larger variable “B”) while a negative correlation
coefficients expresses a negative relationship (the larger
variable “ A”, the smaller variable “B”) (25).
Effect size (r) was determined for each pair of groups with
the formula r= Z/√N [3] (where N= is the total number of
participants in a pair of groups) and we used Cohen's effect
size estimates (0.2 ='small', 0.5 = 'medium' and 0.8 =
'large' effect size) (26).
Results
The main clinical and demographical data regarding the
entire group are presented in table 1. daregardingheentire
group are presented in table 1

Table 1: demographic data of the study population
The mean value of fibrinogen was 301.16 mg/dL (SD ±
63.20). At the psychometric scale HADS-global the
patients presented a mean value of 15.9 (SD ± 7.31), while
at the HADS-D the mean value was 6.41 (SD ± 3.60).
There was a low but statistically significant positive
correlation between fibrinogen and psychological distress
(HADS-global), rs(98)= .30, p= 0.0023 (graph 1).
Graph 1: the statistical correlation between fibrinogen
values and depression symptoms severity assed by HADS
rating scale of a rs(98)= 0.30 and a p value of 0.0023
Also we found a low positive correlation, yet statistically
significant between fibrinogen and depressive symptoms,
HADS-D, rs(98)=.36, p=0.0003. We created two groups of
patients comprising: “non-distress” group with a score
HADS-global <8 and a “distress” group with a score
HADS-global ≥ 8. From the total number of 100 patients
analyzed 16 (16%) were in the “non-distress” group and
84 (84%) were in the “distress” group. Patients from the
“distress” group compared with patients from the “non-
distress” group presented a statistically significantly
higher level of fibrinogen (U= 285.00, Z= -3.640,
p<0.001). However, the effect size was rather small
(r=0.364).
Discussions:
In this study we analyzed the relationship between
fibrinogen as a biological marker and psychological
distress and depressive symptoms. Although the main
limitation of this study remains the small sample size, we
found a statistically significant low positive correlation
between depressive symptoms and elevated plasma
fibrinogen. Also we found a statistically significant low
positive correlation between elevated plasma fibrinogen
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
and psychological distress. Comparing the two groups of
patients that we created (“distress” and “non-distress”
group) we observed a statistically significant higher level
of fibrinogen in patients with psychological distress.
However, the effect size was rather small (r=0.364). Our
study results are consistent with the data reported from
previous studies in literature showing a significant
positive association between depression and fibrinogen.
As a heterogeneous disorder presenting a wide range of
symptoms, the treatment success of depression varies
among patients. Some studies showed that high plasma
fibrinogen levels were associated with a poor
antidepressant response and indicated an elevated
inflammatory status present at non-responders (27).
Geiser et al. found decreased fibrinogen levels in patients
treated with serotonergic antidepressants compared to
patients without use of serotonergic antidepressants and
healthy controls (28), although others did not find that use
of antidepressants in general was associated with
decreased fibrinogen levels ( 16). Also, some suggest that
MDD patients with increased inflammatory protein levels
tend to be treatment resistant (29).
The potential clinical implication of fibrinogen as a
predictive response marker in the case of antidepressant
resistance would be that those specific patients could be
subjected to medication that modulates fibrinogen levels
before starting drug treatment to increase the likelihood of
response. If further studies will confirm the putative use of
fibrinogen level in resistant depressed patients it may be
possible to better manage these patients by not exposing
them to lengthy antidepressants trials but rather to use also
other therapeutically methods.
Conclusions:
Psychological distress and depressive symptoms were
statistically significant and positively correlated with
elevated levels of plasma fibrinogen. Also, patients
presenting psychological distress had higher levels of
plasma fibrinogen compared to patients without
presenting psychological distress, even though the effect
size was rather small.
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***
ORIGINAL ARTICLES

FACTORS ASSOCIATED WITH MEDICATION

ADHERENCE IN PATIENTS WITH
SCHIZOPHRENIA
Ana M. Romoșan1, Felicia Romoșan2, Liana Dehelean3, Mihaela A. Simu4,
Virgil R. Enătescu5, Cristina A. Bredicean6, Ion Papavă7, Iris Druț8,
Mihaela O. Manea9, Ioana Riviș10, Simona D. Rădulescu11, Radu Ș. Romoșan12
ABSTRACT
Introduction: Patients with schizophrenia require medication
that is taken regularly for long periods of time. Non-adherence to
antipsychotics is considered the main reason for hospital
readmission.
Objectives: To assess the prevalence of non-adherence in
schizophrenic patients under antipsychotic treatment and to
identify socio-demographic and clinical factors that might
influence adherence to treatment.
Methods: This prospective study was conducted in several
psychiatric private practices located in Timișoara, between
october 2014 and october 2016 and included 60 patients
diagnosed with paranoid schizophrenia according to ICD-10
criteria, that were followed-up for six months. Clinical
interviews, the BPRS – Brief Psychiatric Rating Scale (used to
assess symptom severity) and a shorter version of the ROMI –
Rating of Medical Influences scale (used to rate patient attitudes
toward adherence) were applied at baseline. The BPRS was also
used in the follow-up visits (once a month). We divided the
patients into two samples considering treatment adherence and
we compared data.
Results: For the whole sample, the mean disorder duration was
12.6 ± 7.6 years and the mean number of hospitalizations was 6.4
± 4.5. Younger patients were more adherent to treatment than
elderly patients, whilst single patients or those living alone were
more frequently non-adherent. We obtained statistically
significant differences between the study groups (adherent vs.
non-adherent) regarding disorder duration (p=0.04) and mean
number of hospitalizations (p=0.02). The main two reasons for
non-adherence to pharmacotherapy were discomfort caused by
the medication's adverse effects (37.5%), and the fact that
medication is not currently needed – from the patient's standpoint
(21.8%). The most important reasons for adherence to
pharmacotherapy were: the perceived daily benefit brought on by
antipsychotic medication (32.1%) and relapse prevention
(17.9%).
Conclusions: Age, marital status, and disorder duration are
factors with the most important influence on treatment
adherence.
Key words: compliance, non-compliance, psychosis,
antipsychotic
REZUMAT
Introducere: Tratamentul schizofreniei necesită medicație
administrată regulat pe termen lung. Non-aderența la medicația
antipsihotică este considerată principalul motiv pentru
reinternările in spital.
Obiective: Evaluarea ratei de non-aderenţă la tratamentul cu
antipsihotice la pacienţii cu schizofrenie, identificarea factorilor
socio-demografici şi clinici care ar putea influenţa aderenţa la
tratament.
Metodă: Studiul a fost efectuat pe 60 de pacienţi, între octombrie
2014 şi octombrie 2016, aflaţi în evidenţă la diverse cabinete
medicale de psihiatrie private din Timișoara, diagnosticaţi cu
schizofrenie paranoidă (conform criteriilor ICD-10) și
monitorizați timp de 6 luni în ceea ce priveşte aderenţa la
tratamentul cu antipsihotice. La evaluarea iniţială au fost
colectate date clinice privind pacienții și au fost aplicate scalele
BPRS – Brief Psychiatric Rating Scale (pentru aprecierea
intensității simptomatologiei psihiatrice) și ROMI – Rating of
Medical Influences (utilizată pentru evaluarea atitudinii
pacienților față de aderența la terapie). Scala BPRS a fost
aplicată ulterior și pe parcursul monitorizării (o dată pe lună). În
funcție de aderență, pacienții au fost împărțiți în două loturi,
analizate comparativ.
Rezultate: La nivelul întregului lot, durata medie a bolii a fost de
12.6 ± 7.6 ani, iar numărul mediu de spitalizări 6.4 ± 4.5.
Aderența la tratament a fost mai bună la pacienții tineri.
Pacienții necăsătoriți și cei trăind singuri au fost mai frecvent
neaderenți. Am obținut diferențe semnificative între cele două
loturi (aderenți vs. neaderenți) privind durata bolii (p=0.04) și
durata medie a spitalizării (p=0.02). Principalele motive pentru
non-aderență au fost disconfortul cauzat de efectele adverse ale
medicației (37.5%) și faptul că tratamentul nu mai este necesar –
din punctul de vedere al pacientului (21.8%). Cele mai
importante motive pentru aderența la terapie au fost considerate:
beneficiul zilnic adus de către medicația antipsihotică (32.1%) și
prevenirea recăderilor (17.9%).
Concluzii: Vârsta, statutul marital și durata bolii sunt factori
care influențează aderența pacienților la tratament.
Cuvinte cheie: complianță, non-complianță, psihoză,

1
MD, PhD Candidate, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania; 4th year medical resident in adult psychiatry,
SCJUPB Timisoara.
2
MD, PhD, Mara Institute, Timișoara, Romania.
3
MD, PhD, Associate Professor, Department of Neuroscience, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania.
4
MD, PhD, Professor, Department of Neuroscience, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania.
5
MD, PhD, University Lecturer, Department of Neuroscience, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania.
6
MD, PhD, University Lecturer, Department of Neuroscience, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania.
7
MD, PhD, Assistant Professor, Department of Neuroscience, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania.
8
MD, PhD Candidate, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania; 2nd year medical resident in adult psychiatry,
SCJUPB Timisoara.
9
MD, PhD Candidate, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania.
10
MD, 3rd year medical resident in adult psychiatry, SCJUPB Timisoara.
11
MD, PhD Candidate, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania; 4th year medical resident in adult psychiatry,
SCJUPB Timisoara.
12
MD, PhD, Assistant Professor, Department of Neuroscience, ”Victor Babeş” University of Medicine and Pharmacy Timişoara, Romania.
Correspondence to:Romoşan Radu-Ștefan, MD PhDAsst. Prof., Department of Neuroscience, Discipline of Psychiatry, 2 Eftimie Murgu Street,
300041, Timişoara Tel: +40724.981.888, E-mail: romosan.radu@gmail.com
Received November 19, 2016, Revised January 11, 2017, Accepted January 31, 2017
59
Ana M. Romoșan, Felicia Romoșan, Liana Dehelean, Mihaela A. Simu, Virgil R. Enătescu, Cristina A. Bredicean, Ion
Papavă, Iris Druț, Mihaela O. Manea, Ioana Riviș, Simona D. Rădulescu, Radu Ș. Romoșan: Factors Associated with
Medication Adherence in Patients with Schizophrenia
INTRODUCTION
From the perspective of any disorder with a
significant degree of chronicisation, including
schizophrenia, ensuring patient adherence to medical
treatment starting from the first episode of the illness is
essential. The treatment's main objective for patients with
schizophrenia is full control of symptoms with minimal
impact on functioning, thus ensuring optimal quality of
life. The chronic evolution of the disorder translates into
the fact that most patients require antipsychotic
medication for long periods of time, sometimes life-long,
in order to achieve good control of symptoms and to
prevent the recurrence of acute psychotic episodes and
progressive cognitive impairment that are associated with
them (1,2). Therefore, constant adherence to
antipsychotic treatment is a major determinant for a
favorable outcome. Unfortunately, a significant
proportion of patients do not adhere to therapeutic
indications. Treatment non-adherence rates in patients
with schizophrenia cited in the literature varies,
depending on the authors and the definition itself: between
20% and 89%(3) with an average of 49% of cases(4). The
most significant consequences of antipsychotic treatment
discontinuation are: increased number of relapses and
hospitalizations, increased severity of symptoms during
relapse, worsening of residual symptoms, substance
abuse, and increased social cost (5,6,7). Although factors
which influence adherence frequently overlap or
influence each other, it's still possible to distinguish
factors related to: the patient (psychopathology, cognitive
impairment, age, gender, personality traits, absence of
insight, cultural beliefs regarding illness and health),
treatment (tolerance, duration of treatment, onset of action
and efficacy, unrealistic expectations in terms of benefit /
risk ratio, delayed therapeutic effect and early side effects,
subjective discomfort caused by the side effects),
environmental (social environmental attitude towards the
psychiatric treatment, availability of the family to support,
assist and supervise the treatment, social support, stigma,
financial situation), therapist-related factors (patient-
psychiatrist relationship, therapeutic alliance, informing
the patient about the disorder and treatment, perceived
interest regarding the therapist's interest towards the
patient's problems) (8,9,10). Adherence to treatment in
schizophrenia is also affected by the duration and the
consequences of discontinuing the medication: the
consequences of non-adherence are mitigated by the
insidious manner in which symptoms develop after
treatment is discontinued so that the relationship between
cause and effect becomes sometimes blurred both for
patients and family, which can lead to maintaining non-
adherent behavior. Although this grouping of factors is
somewhat artificial, it can help the clinician to detect the
various reasons for which the patient has developed non-
adherence issues and to intervene accordingly.
The aim of the study was to assess the rate of non-
adherence to antipsychotic treatment in outpatients with
schizophrenia, to identify socio-demographic and clinical
factors that may influence adherence to treatment and to
record the reasons given by the patients as to why adherent
or non-adherent behavior occurred.
MATERIALS AND METHODS
The study involved 60 patients diagnosed with
schizophrenia from various psychiatric private practices
60
located in Timișoara, Romania from October 2014 to
October 2016. Inclusion criteria in the study were age
between 18 and 65 years, the International Classification
of Diseases 10 (ICD-10) diagnosis of paranoid
schizophrenia, and the prescription of at least one
antipsychotic agent. Cases of abuse or addiction to alcohol
or drugs and those with limited capacity to give valid
consent were excluded from the study. All patients used
conventional or atypical antipsychotics and the method of
administration was oral. Upon study entry, patients gave
their informed consent and the research was approved by
the local ethics committee. The study was conducted
according to the principles stated in the Helsinki
Declaration and the authors received no funding from any
source.
Demographic and clinical characteristics of the
patients (gender, age, marital status, educational status,
professional status, the clinical form of schizophrenia, the
duration of illness, number of hospitalizations, and
antipsychotics used) were recorded. Data was obtained
from the medical records supplied by the clinician and
from the patients during the interview.
The term “adherence” was defined as the degree
to which individuals follow directions for taking
prescribed medication. Medication adherence was
assessed through physicians` subjective perception, by
direct questioning the patient or by questioning a family
member. Adherence was assessed monthly by using the
report given by a family member designated as
responsible for this task. Non-adherence was defined as
taking less than 75% of the prescribed dose within the
preceding 30 days (adapted from Buchanan et al.,1992)
(11).
At baseline, positive and negative symptoms and
severity of hallucinations and thought disorder
(conceptual disorganization) were quantified using BPRS
(Brief Psychiatric Rating Scale) – the extended version,
with 24 items (12).
An abbreviated version of the Rating of
Medication Influences (ROMI) Scale was used to assess
the attitudinal and behavioral factors that influence
medication adherence (13). The ROMI Scale is a self-
assessment scale which has two parts, the first part being
semi-structured and includes questions about the patient's
lifestyle, treatment, patient and family attitudes towards
treatment, active/passive adherence. The second part of
the scale is divided into two sections, comprising the main
reasons for adherence or non-adherence. This study used
the second part of the ROMI Scale.
After clinical interview, the BPRS Scale and
the ROMI Scale were applied at baseline. We divided the
patients into two groups (adherent and non-adherent to
treatment), that were assessed comparatively. The BPRS
was used in the follow-up visits (on a monthly basis).
Data were analyzed using IBM SPSS Statistics
for Windows (version 20). Statistical data processing
calculated the statistic descriptive indicators, frequency,
mean and standard deviation for numerical data. Because
of the relative small sample size, a normality test was
applied (the Shapiro-Wilk normality test). The test
revealed a non-gaussian data distribution and therefore, to
compare groups, we used a non-parametrical test (the
Mann-Whitney U test). For comparing categorical data,
we utilized the χ² test. The level of significance was set at

0.05. All results were two-tailed.
RESULTS
Baseline characteristics of the patients are
presented in Table 1.
Thirty-one were female (51.7%) and twenty-
nine (48.3%) male and their mean age was 36 years
(SD=11.4). Out of the 60 patients, 23 (38.3%) were
married, 37 (61.7%) were single (not married, separated or
divorced). Upon entry into the study 23 patients (38.3%)
were employed, 28 (46.7%) were retired and 9 of them
(15%) were unemployed. In terms of educational level 27
of them (45%) had completed elementary school, 28
(46.7%) were high school graduates and 5 (8.3%) college
or university graduates.
We noted statistically significant differences
between groups considering mean age, the duration of the
illness and mean number of hospitalizations, as can be
observed in Table 2.
We noticed that younger patients were more
adherent to treatment than elderly patients, whilst non-
adherent were significantly more frequent single patients
(χ²=2.315, p=0.05) and those living alone (χ²=3.115,
p=0.002). We found no significant statistical associations
between adherence and educational level (χ²=0.21,
p=0.156), between adherence and professional status
(χ²=0.159, p=0.23), or between adherence and gender
(χ²=0.135, p=0.38).
The mean BPRS values obtained in the
evaluations show a mild severity of symptomatology,
which was maintained relatively constant during the study
in both groups of patients. The difference between the
groups during the direct evaluation regarding increased
symptom severity in the non-adherent group was not
validated from a statistical point of view (Table 3).
Another aspect studied was the patient's
motivation towards medication adherence or non-
adherence. The most important reasons for adherence,
after ROMI Scale were: the perceived daily benefit
brought on by antipsychotic medication (increased quality
of sleep, decreased anxiety levels, diminished
hallucination frequency and intensity, increased control
over their thoughts), relapse prevention, positive family
beliefs and supervision, fear of being hospitalized and a
positive patient-clinician relationship (Table 4).
The most important reasons for non-adherence
were discomfort caused by the adverse effects of the
medication (extrapyramidal and anticholinergic effects,
weight gain), followed by “medication is not currently
needed” – from the patient's perspective, denial of illness,
treatment without benefit, social stigma and interference
with ideals in life, opposition from family. Data are
presented in Table 5.
DISCUSSIONS
The study investigated reported non-adherent
forms of behavior and their detection by clinicians in
patients with paranoid schizophrenia. Before discussing
the findings in detail, it is important to comment on the use
of self-report measures of adherence. No method of
adherence assessment is perfect, but the specificity of self-
report is considered to be comparable with plasma
measurements and event monitoring techniques (14).
Stephenson (15) suggests that the sensitivity of self-report
is less reliable but is a simple and low-burden measure that
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
can be applied to a large sample of patients. The rate of
non-adherence found in our sample over a 6-month period
(53.30 %) is in agreement with those found in the literature
– approximately 50% (11,15,16,17). Socio-demographic
characteristics did not differ much between patients who
had good adherence and those who were non-adherent.
The non-adherent group had a higher mean age at the
baseline assessment than those in the adherent group.
Literature is equivocal in terms of age, some studies
finding more often non-adherent behavior in young age
groups (10,18), other report adherence problems in older
people (19,20). Possible explanations are the tendency to
be non-conformant, thus refusing to follow a rigorous,
planned schedule for the young and in the case of older
people the potential presence of memory disorders and
concomitant medication for various somatic disorders that
may contribute to lower adherence (21,22). A significant
correlation was found regarding non-adherent behavior
and the marital status. Single patients and especially the
ones who lived alone were more likely to be non-adherent.
The correlation found between illness duration and non-
adherent behavior is in concordance with the literature
data, supporting the idea that risk for non-adherence
increases in parallel with the disorder duration, and
acknowledged as being present in other chronic
psychiatric or non-psychiatric disorders (23,24). The
mean number of hospitalizations/ non-adherent case
suggests the role of risk factors for relapses and
consequently a more unfavorable development which can
occur because of non-adherence to treatment. A
significant difference regarding symptom severity
between adherent and non-adherent patients was not
found in our study. The severity of the disorder has been
found by many authors to correlate with adherence, which
is understandable since patients presenting more severe
psychopathology would be expected to be less adherent to
treatment. On the other hand, it's known that non-
adherence to treatment is determined by multiple factors,
including the severity of symptoms but this is not
considered a unique and necessary cause (11,25). The
main motivation for adherence was the perception of a
potential benefit. Patients need to feel better, regarding
something that disturbed them (example: sleep
disturbance, anxiety, hallucinations). The perception of
benefit and a subjective perception of well-being seem to
have been more consistently correlated with adherence
(26). Supervising the intake of medication by family or
friends and positive attitudes towards medication was
frequent in the adherent patients. A positive relationship
with the clinician was quoted by only 10.71% of patients
as a reason for adherence. In other studies, this reason is
more frequently cited (27)than in our study. The clinician-
patient relationship is however difficult to assess in terms
of methodology. It is widely recognized that a good
therapeutic alliance can influence patient attitude towards
the disorder and treatment. The information the clinician
provides his patients with, regarding the disorder, about
the effects and usefulness of treatment, also about their
side effects, can significantly contribute to improving
adherence. The most common reason quoted by non-
adherent patients was the adverse effects of
antipsychotics. Side effects, particularly extrapyramidal
and anticholinergic effects are the source of considerable
distress, they have a stigmatizing role and potentially
61
Ana M. Romoșan, Felicia Romoșan, Liana Dehelean, Mihaela A. Simu, Virgil R. Enătescu, Cristina A. Bredicean, Ion
Papavă, Iris Druț, Mihaela O. Manea, Ioana Riviș, Simona D. Rădulescu, Radu Ș. Romoșan: Factors Associated with
Medication Adherence in Patients with Schizophrenia
unpleasant consequences, decreasing the patient's quality
of life as well as his desire to take antipsychotic
medication ever again. The next reason quoted by the
patients was that medication is not necessary now,
reflecting the response of patients on disease knowledge
and beliefs. It is obvious that if the patient feels well and
believes that schizophrenia is an unimportant disorder that
doesn't require continuous treatment, adherence will be
compromised.
CONCLUSIONS
In the present study, we found a high rate of non-
adherence during the 6-month follow-up of outpatients
with schizophrenia. Non-adherent behavior was more
frequently found in the elderly and in those living alone.
Disorder duration and the mean number of
hospitalizations per case were higher in the non-adherent
group, the second variable suggesting the role of risk
factor for relapse that non-adherence to treatment
represents. In the opinion of the assessed patients, the
most important reason for adherence was the perception of
the daily benefit brought by the medication and for non-
adherence the discomfort caused by the side effects of the
antipsychotics. Identifying and understanding the reasons
for non-adherence to treatment represents a strategy of
improving the patient's commitment in long-term therapy.
The results suggest that outpatients with schizophrenia
who have various reasons for non-adherence are
associated with actual non-adherence and the ROMI Scale
may be useful for predicting such behavior. Improved
treatment adherence in schizophrenia can reduce the risk
of relapse and its morbid consequences and perhaps
promote higher functioning through better therapeutic
engagement.
LIMITATIONS
Our study must be interpreted in light of some limitations:
the relatively small patient samples, adherence wasn't
studied according to antipsychotic classes, which could
have (potentially) influenced the end results. Like other
studies of medication adherence among individuals with
psychotic disorders, the present study was hampered by
inherent selection biases, because individuals who
consent to participate in such research and complete the
required assessment are likely to be more compliant in
taking medication.
AKNOWLEDGEMENTS
All authors have contributed equally to the present study
and approved its final version.
DISCLOSURES
The authors have no conflict of interest to disclose for the
present article.
LIST OF ABREVIATIONS
BPRS: Brief Psychiatric Rating Scale
ROMI: Rating of Medication Influences

Table 1 – Socio-demographic data – adherent / non-adherent group

Adherent Non-adherent Statistical
n = 28 n = 32 significance

Mean age (± SD) at baseline 32.8 ± 6.8 years 36.9 ± 7.08 years Z=-2.043
assessment p=0.04

Males 11 18 χ2=4.93
Sex p=0.09
Females 17 14
Married 16 7 χ2=7.95
Marital status p=0.05
Single 12 25
Elementary school 11 16
χ2=5.40
Educational level High school 14 14 p=0.06
College/University 3 2
Employed 14 9
χ2=3.62
Professional status Retired 10 18 p=0.159
Unemployed 4 5

62
 Romanian Journal of Psychiatry, vol. XIX, No.2, 2017

Table 2 – Clinical variables

Adherent Non-adherent Statistical
n = 28 n = 32 significance

Mean age (±SD) Z=-2.043

32.8 ± 6.8 36.9 ± 7.08 p=0.04

Mean disorder duration (±SD) 8.72 ± 6.31 12.27 ± 8.04 Z=-2.07

p=0.04

Mean number of 5.29 ± 2.13 7.63 ± 4.15 Z=-3.31

hospitalizations / case (±SD) p=0.02

Table 3 – Mean BPRS-A Scale Scores – adherent / non-adherent groups

Duration of follow- Adherent (n=28) – BPRS mean Non-adherent (n=32) – BPRS
up (months) scores (±SD) mean scores (±SD)
0 29.50 ± 4.81 29.62 ± 5.72
1 29.76 ± 5.86 30.20 ± 6.54
2 28.58 ± 5.57 33.84 ± 7.50
3 28.42 ± 5.57 33.18 ± 7.95
4 27.80 ± 5.76 35.26 ± 8.04
5 26.96 ± 5.54 36.05 ± 7.07
6 26.88 ± 5.63 36.27 ± 7.93

Table 4 – Reasons for treatment adherence

Most frequent reasons for adherence Number of patients %

Perceived benefit brought by medication 9 32.1

Relapse prevention 5 17.9
Family supervision and attitude towards treatment 4 14.3
Fear of being hospitalized 4 14.3
Positive patient-clinician relationship 3 10.7
Insistence from family members 2 7.1
Respect for authority 1 3.6

63
Ana M. Romoșan, Felicia Romoșan, Liana Dehelean, Mihaela A. Simu, Virgil R. Enătescu, Cristina A. Bredicean, Ion
Papavă, Iris Druț, Mihaela O. Manea, Ioana Riviș, Simona D. Rădulescu, Radu Ș. Romoșan: Factors Associated with
Medication Adherence in Patients with Schizophrenia
Table 5 – Reasons for non-adherence
Most frequent reasons for non-adherence
Discomfort caused by side effects
Medication is not necessary at present
Denial of illness
Treatment brings no benefits
Social stigma
Interference with ideals in life
Opposition from family / friend(s)
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Effects on brain morphology in first episode psychosis. Arch. General
Psychiatry 2005; 62: 361-70.
2.McCabe R, Bullenkamp J, Hansson L et al. The therapeutic
relationship and adherence to antipsychotic medication in
schizophrenia. PLoS One 2012; 7(4):1–5
3.Knapp M, King D, Pugner K. Non-adherence to antipsychotic
medication regimens Associations with resource use and costs. Br J
Psychiatry 2004; 184: 509-16.
4.Naber D, Karow A, Lambert M. Subjective well-being under
neuroleptic treatment and its relevance for compliance. Acta
Psychiatrica Scandinavica 2005; 111(427): 29-34.
5.Christy LM Hui, Eric YH, Chen CS et al. Detection of non-adherent
behavior in early psychosis. Australian and New Zealand Journal of
Psychiatry 2006; 40: 446-451.
6.DiBonventura M, Gabriel S, Dupclay L, Gupta S, Kim E. A patient
perspective of the impact of medication side effects on adherence: results
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BMC Psychiatry 2012; 12:20.
7.Nicolino PS, Vedana KG, Miasso AI, Cardoso L, Galera SA.
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8.Woerner MG, Mannuzza S, Kane JM. Anchoring the BPRS: an aid to
improve reliability. Psychopharmacol Bull 1988; 24 (1): 112-17.
9.Novick D, Haro JM, Hong J et al. Regional differences in treatment
response and three year course of schizophrenia across the world. J
Psychiatr Res 2012; 46:856–864.
10.Lee H, Kane I, Sereika SM, Cho RI, Jolley CJ. Medication-taking
behaviours in young adults with schizophrenia: a pilot study. J Psychiatr
Ment Health Nurs 2011; 18:418–424.
11.Buchanan A. A Two Year Prospective Study of Patients with treatment
compliance in schizophrenia. Psychol Med 1992; 22 (3): 787-97.
12.Lukoff D, Nuechterlein KH, Ventura J. Manual for the Expanded
BPRS. Schizophrenia Bull 1986; 12:584-602.
13.Waiden P, Rapkin B, Mott T. Rating of medication Influences (ROMA
Scale) in schizophrenia. Schizophr Bull 1994; 20: 297-310.
14.Byerly M, Fisher R, Whateley C et al. A comparison of electronic
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Number of patients %
12 37.5
7 21.9
5 15.6
3 9.4
2 6.3
2 6.3
1 3
monitoring vs. clinician rating of antipsychotic adherence's in
Outpatients with schizophrenia. Psychiatry Research 2005; 28: 129-33.
15.Stephenson BJ, Rowe BH, Haynes RB et al. Is this patient taking the
treatment as prescribed? JAMA 1993; 269: 2779-81.
16.Adams J, Scott J. Predicting medication adherence in severe mental
disorders. Acta Psyh Scan 2000; 101: 119-24.
17.Dolder CR, Lacro JP, Dunn LB et al. Antipsychotic medication
adherence: There is a difference between typical and atypical agents.
American Journal of Psychiatry 2002; 159: 103-12.
18.Hudson TJ, Owen RR, CR Trush et al. A Pilot Study of barriers to
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19.Fleischnacker WW, Oehl MA, Humera M. Factors influencing
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20.Ritchie CW, Harrigan S, Mastwyk M et al. Predictors of adherence to
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21.Kim SW, Shin IS, Kim JM et al. Association between attitude towards
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ORIGINAL ARTICLES

METABOLIC ASSESSMENT AND QUALITY OF

LIFE IN A SAMPLE OF PATIENTS IN TREATMENT
WITH OLANZAPINE DEPOT
Ana-Anca Talașman¹, Mihaela Nae2, Alexandra Dolfi3,Irina Luca4, Mihai V Zamfir5

Abstract:
BACKGROUND: Non adherence to medication is a major
risk factor contributing to relapse and hospitalization
among patients with schizophrenia. Treatment with
antipsychotics in depot
formulations is recognized as safe and effective for
improving medication adherence.(1)
OBJECTIVES: Metabolic and quality of life assessment of
patients treated with olanzapine depot
METHODS: We studied 24 patients in treatment with
olanzapine depot, monitored between 2011-2017. For
metabolic assessment we used data from patients' clinical
recordings (variation in Blood Pressure, glycaemia ,
cholesterol, triglycerides, BMI) and for quality of life
assessment SF-36.questionnaire and data regarding
socio-professional, familial reinsertion, number of
relapses and hospitalisations obtained from clinical
interview.
RESULTS: The studied sample comprised 16 men and 8
women, diagnosed with schizophrenia, most of them being
previously treated with oral olanzapine. Most of the
patients were under treatment with olanzapine depot
300mg i.m.,two shots per month (at 2 weeks distance). Two
patients lost weight, the majority of them had no
significant variation in BMI, one patient with increase of
8,4units in BMI, two patients with stable BMI. 7 of 12
patients had increased cholesterol levels, the rest of
biological parameters being normal. Two patients had
post-injectional somnolence. 13 patients had no relapses,
3 patients were noncompliant, 3 had relapses, 3 were lost
from monitoring and 2 were changed on orally
administered olanzapine. 4 patients had total score above
50 at the mental component of SF-36 and 4of them had
total scoreabove 50 at the physical component of SF-36.
CONCLUSION: In the studied sample, most of the patients
had a favourable evolution regarding clinical aspects,
familial and socio-professional reinsertion and metabolic
outcomes, which confirms the fact that olanzapine depot is
a safe treatment associated with low incidence of relapses.
Further studies are needed on large samples, in order to
evaluate quality of life in patients treated with olanzapine
depot.
Key words: treatment adherence, quality of life,
olanzapine depot

BACKGROUND: and vital signs). For metabolic assessment we used data

Non adherence to medication is a major risk factor
contributing to relapse and hospitalisation among patients
with schizophrenia(1). Treatment with antipsychotics in
depot
formulations is recognized as safe and effective for
improving medication adherence and it appears to benefit
non compliant patients with schizophrenia(1).
Hospitalization is a costing and stressful event associated
with relapse during treatment of patients with
schizophrenia (2). Olanzapine depot was associated with a
significant lower incidence of hospitalizations and a
shorter duration of hospitalization compared to olanzapine
administered orally in therapeutic dose (2).
METHODS:
We studied 24 patients in treatment with olanzapine depot,
monitored between 2011-2017. At every visit patients
were monitored for 3 hours in the hospital(clinical state
from patients' clinical recordings (variation in Blood
Pressure, glycaemia, cholesterol, triglycerides, BMI) and
for quality of life assessment SF-36 questionnaire which
we applied to 6 of the 13 patients who are still monitored
and data regarding socio-professional, familial
reinsertion, number of relapses and hospitalisations
obtained from clinical interview.
RESULTS:
The studied sample comprised 16 men and 8 women,
minimum age 28, maximum age 57 at the beginning of
treatment, diagnosed with schizophrenia, 18 patients in
anterior treatment with oral olanzapine, 1 with
flupenthyxol, 1 with aripiprazole, 1 with amisulpride, 2
with quetiapine and 1 with risperidone.
Olanzapine depot dosage used were the following: 8
patients on 405 mg/month i.m., 15 patients with 300mg /2
weeks i.m., one patient with 210mg/2 weeks.

¹Senior Psychiatrist at The Clinical Hospital of Psychiatry”Prof. Dr. Alexandru Obregia” No.10 Berceni Road , District 4, Bucharest,e-mail:
anaanca@yahoo.com
²Psychiatrist at Clinical Emergency Hospital”Sf. Ioan”, No.13 Vitan-Birzesti Road, District 4, Bucharest, e-mail:naemhl@yahoo.com
³Resident in Psychiatry at The Clinical Hospital of Psychiatry”Prof. Dr. Alexandru Obregia” No.10 Berceni Road , District 4, Bucharest,e-
mail:dolfialexandra@gmail.com
4
Resident in Psychiatry at The Clinical Hospital of Psychiatry”Prof. Dr. Alexandru Obregia” No.10 Berceni Road , District 4, Bucharest,e-
mail:irina_luca08@yahoo.com
5
Physiology - Neurosciences Division, Faculty of Medicine, ”Carol Davila”University of Medicine and Pharmacy, Bucharest
Received December 3, 2016, Revised December 11, 2016, Accepted December 22, 2016

65
Ana-Anca Talașman,Mihaela Nae, Alexandra Dolfi,Irina Luca, Mihai V Zamfir: Metabolic Assessment and Quality of
Life in a Sample of Patients in Treatment With Olanzapine Depot (zypadhera)

for all monitored patients.

Triglycerides- all values within normal limits.
Cholesterol- 7 out of 12 patients had values above the
normal limit.
BP and pulse- values were in normal limits for all
monitored patients.
TGO and TGP were normal in majority of patients.

Figure no.3

Figure no. 1

Figure no. 4

Figure no. 2

Biological parameters monitored:

BMI-2 patients lost weight, most of them without Figure no.5
significant variation in BMI, one patient with significant
variation (an increase of BMI of 8.4 units), 2 patients with
stable weight. Glycaemia- values were in normal limits

66
 Romanian Journal of Psychiatry, vol. XIX, No.2, 2017

N Mini Maxi Mean Std. We registered 2 adverse events, two patients with
mum mum Deviation post injection somnolence. The two patients were
Gender 24 0 1 .33 .482 administered i.v. fluids and were monitored until next day
Age at beginning of 23 25.0 57.0 37.522 9.7602 in the hospital, their outcome being favourable and
treatment continued treatment with olanzapine depot with good
Dosage 24 0 2 1.29 .550 evolution at the present time.
No of visits 24 5 112 50.83 32.979 13 patients of the 24 monitored ones had no relapses, 3
BMIvariation 24 -2.1 8.4 1.296 2.0733 patients had relapses after 5 yers of treatment with
Glycaemiamedium 13 80 159 94.85 20.301 olanzapine depot, 3 patients were noncompliant after 5
TGMedium 12 56 292 133.08 69.886 years of treatment, 3 were lost from monitoring and 2 were
CholMedium 12 110 330 199.67 60.426 changed on orally administered olanzapine, on request
TGOmedium 13 12 34 22.69 6.688
TGPmedium 12 3 258 42.08 69.246
BPsMedium 14 100 140 120.36 12.475
PulseMedium 12 70 90 79.83 5.797
Initial treatment 23 1 5 3.04 .706
Relapse 24 0 1 .13 .338
Glycaemiamedium 13 .00 1.00 .0769 .27735
CAT
TGmediumCAT 12 .00 1.00 .4167 .51493
CholmediumCAT 12 .00 1.00 .5833 .51493

Table no.1 Descriptive Statistics

Conventions: 0=man Dosage: 0=210 1=300 4=405 For
a simple analysis we kept only systolic BP values.

Figure no.8

Figure no. 6

Figure no.7 Figure no. 9

67
Ana-Anca Talașman,Mihaela Nae, Alexandra Dolfi,Irina Luca, Mihai V Zamfir: Metabolic Assessment and Quality of
Life in a Sample of Patients in Treatment With Olanzapine Depot (zypadhera)
SF-36 questionnaire results: mental component- 4
patients obtained total score above 50, one patient a total
score of 50 and one patient a score under 50; physical
component- 4 patients with the total score above medium
and 2 with a score under the medium.
Figure no. 10
Figure no. 11
68
3 of our studied patients are employed, most of the
monitored patients come alone to treatment, after only 2-3
years of treatment they became independent, all of the
patients respect the visits' schedule and they stay 3 hours
in the hospital, being monitored at every visit.
CONCLUSION:
Schizophrenia is a chronic disease in which relapses are
frequent during the life of the patients (2,3). During the
relapse the patient might be admitted to hospital for acute
treatment and control of psychotic symptoms, fact that can
lead to added costs and delays recovery (4,5), reducing
quality of life in these patients(6). This is why, it must be
found a treatment that contributes to increase in
adherence, lowering of the relapses and the costs and
improvement in quality of life of the patients.
In the studied sample, most of the patients had a
favourable outcome regarding clinical aspects, familial
and socio-professional reinsertion and metabolic
evolution, which confirms the fact that olanzapine depot is
a safe treatment associated with low incidence of relapses
which implies a low number of hospitalisations.
Further studies are needed, on larger samples, in order to
evaluate quality of life in patients treated with olanzapine
depot.
REFERENCES:
1.Ascher-Svanum H, Montgomery W, McDonnell D, Coleman K,
Feldman P. Treatment-completion rates with olanzapine long-acting
injection versus risperidone long-acting injection in a 12-month, open-
label treatment of schizophrenia: indirect, exploratory comparison.
International Journal of General Medicine 2012; 5: 391–398.
2.Ascher-Svanum H et al. Predictors of psychiatric hospitalization
during 6 months of maintenance treatment with olanzapine long-acting
injection: post hoc analysis of a randomized, double-blind study. BMC
Psychiatry 2013; 13:224. http://www.biomedcentral.com/1471-
244X/13/224
3.Citrome L. New second-generation long-acting injectable
antipsychotics for the treatment of schizophrenia. Expert Rev of
Neurother 2013; 13(7):767-783, DOI: 10.1586/14737175.2013.811984
4.Robinson D, Woerner MG, Alvir JM, Bilder R, Goldman R, Geisler S,
Koreen A, Sheitman B, Chakos M, Mayerhoff D, Lieberman JA:
Predictors of relapse following response from a first episode of
schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999,
56:241–247.
5.Lieberman JA, Koreen AR, Chakos M, Sheitman B, Woerner M, Alvir
JM, Bilder R: Factors influencing treatment response and outcome of
first episode schizophrenia: implications for understanding the
pathophysiology of schizophrenia. J Clin Psychiatry 1996; 57(Suppl
9):5–9.
6. Almond S, Knapp M, Francois C, Toumi M, Brugha T: Relapse in
schizophrenia: costs, clinical outcomes and quality of life. Br J
Psychiatry 2004; 184:346–351.
***
ORIGINAL ARTICLES

POSTOPERATIVE DELIRIUM INCIDENCE AND

OXIDATIVE STRESS IN LAPAROSCOPIC
SURGERY
Andreea D. Stanculescu1, Dominic G. Iliescu2, Octavian Dragoescu3, Andrei Drocas4,
Mihail C. Pirlog5, Stefania Tudorache 6, Florea Purcaru 7, Traian Purnichi8,
Nicoleta A. Dragoescu9

ABSTRACT: Postoperative delirium is a common
complication of all types of surgery, especially in elderly
patients (2). Overproduction of free oxygen radicals and
decrease of organism defense mechanisms is believed to be
involved in multiorgan failure, especially in the brain (4).
It is important to determinate the susceptibility, incidence
and preventive measures for postoperative delirium (8).
Our objective was to identify an oxidative stress indicator
that predicts the appearance of postoperative delirium in
patients that undergoes laparoscopic renal or
gynecological surgery for malignant diseases and the
possible correlations between certain anesthetic drugs
and postoperative delirium occurrence. This study
included 29 patients that were treated for localized kidney
or uterine cancer by trans peritoneal laparoscopic radical
surgery procedures (nephrectomy or hysterectomy)
between 2014 and 2016. They were randomized in two
groups: the sevoflurane group (n=14 patients) and
propofol group (n=15 patients). Blood samples were
collected before anesthesia induction, at the end of surgery
and at 24 h after surgery and the levels of malondialdehyde
(MDA) and superoxide dismutase (SOD) were measured.
Postoperative delirium was assessed using Confusion
Assessment Method for the ICU (CAM-ICU). All patients
with delirium from both groups developed the condition on
the first postoperative day. In the sevoflurane group,
postoperative delirium has observed in 6/14 patients
(42%) and in the propofol group, 5/15 patients (33%) have
developed the same postoperative syndrome. There was a
significant increase of malondialdehyde levels in the
delirium group compared to the non-delirium group in
patients, sevoflurane and propofol, at the end of surgery.
(p<0.05) There were statistical difference between
delirium group and non-delirium group in both
sevoflurane and propofol patients, regarding superoxide
dismutase levels before anesthesia induction (p<0.05).
Postoperative delirium incidence can be predicted by
preoperative superoxide dismutase levels assessment in
patients that undergoes laparoscopic urologic or
gynecological surgery for malignant diseases.
Key words: postoperative delirium, superoxide dismutase,
propofol.

INTRODUCTION Postoperative delirium is a common

Delirium is a transient mental syndrome of acute
onset which is defined by global impairment of cognitive
status, a reduced level of consciousness, perceptual and
emotional disturbances, impairment of attention,
psychomotor activity abnormalities and impairment of
sleep, secondary to a general medical condition (1), having
a complex multifactorial, and not yet fully understood,
etiology.
Delirium represents the most common
psychiatric syndrome which appear in the general hospital
setting, affecting between 15% and 60% of medical and
surgical inpatients. (2) It is correlated with increased
morbidity and mortality, prolonged hospital stays, and
decline of cognitive status. (3, 4, 5) The prevalence of
delirium in postoperative patients ranges from 10% to
51%. (6)
complication of all types of surgery, especially in elderly
patients. The incidence of delirium in elderly
postoperative patients is 15% to 53% and as high as 80% in
elderly patients that require intensive care. (7) One-quarter
of delirious elderly patients dies within 6 months. (8)
The cause of the high incidence of postoperative
delirium in elderly patients is unclear, but a few
mechanisms were proposed. The pathophysiology of
delirium is associated with a variety of etiologies: reduced
cerebral perfusion/oxygenation (9, 10), imbalance of
noradrenergic/cholinergic neurotransmission (11),
imbalance of phenylalanine/tryptophan (12), preoperative
cognitive dysfunction, as well as low antioxidant levels.
(13)
Increased oxidative activity associated with
decreased antioxidative parameters during surgery was

1
MD, Department of Anesthesia and Intensive Care, Emergency Clinical Hospital Craiova, Romania
2
Lecturer, MD, PhD, Department of Obstetrics and Gynecology, University of Medicine and Pharmacy Craiova, Romania
3
Lecturer, MD, PhD, Department of Urology, University of Medicine and Pharmacy Craiova, Romania
4
MD, PhD, Department of Urology, University of Medicine and Pharmacy Craiova, Romania
5
Lecturer, Department of Medical Sociology, University of Medicine and Pharmacy Craiova, Romania
6
Assos. Prof., MD, PhD Department of Obstetrics and Gynecology, University of Medicine and Pharmacy Craiova, Romania
7
Prof. MD, PhD, Department of Anesthesia and Intensive Care, University of Medicine and Pharmacy Craiova, Romania
8
MD, PhD student at University of Medicine and Pharmacy Craiova, Romania
9
Lecturer, MD, PhD, Department of Anesthesia and Intensive Care, University of Medicine and Pharmacy Craiova, Romania
Correspondence author: Iliescu Dominic Gabriel, Str. Tabaci, no.1, Craiova, +40723888773, dominic.iliescu@yahoo.com
Received December 10, 2016, Revised December 16, 2016, Accepted December 28, 2016
69
Andreea D. Stanculescu, Dominic G. Iliescu, Octavian Dragoescu, Andrei Drocas, Mihail C. Pirlog, Stefania
Tudorache, Florea Purcaru, Traian Purnichi, Nicoleta A. Dragoescu: Postoperative Delirium Incidence and Oxidative
Stress in Laparoscopic Surgery
proved by various studies. Oxidative stress means an
increased formation of free radicals. The most affected
organ during the oxidative stress is the cerebral tissue
because it has large lipid content, an increased oxidative
metabolism and a low antioxidant status. (13) Therefore,
the cerebral tissue is highly affected by the increased free
oxygen radicals, hydrogen peroxide and superoxide
radicals. (14)
The organism tries to protect itself against free
oxygen radicals and produces antioxidant enzymes, such
as superoxide dismutase (SOD), glutathione peroxidase
(GSH) or catalase (CAT), which represent a protective
mechanism. (13)
Overproduction of free oxygen radicals and
decrease of organism defense mechanisms is believed to
be involved in multiorgan failure, especially in the brain. It
is important to determinate the susceptibility, incidence
and preventive measures for postoperative delirium. It has
been confirmed that oxidative stress markers and
antioxidative markers can predict postoperative delirium
occurrence in cardiopulmonary bypass surgery. (13)
There are only few studies concerning the
correlation between oxidative stress, antioxidant activity,
anesthetic drugs and postoperative delirium in
laparoscopic surgery for urogenital malign pathologies.
The aim of this paper is to identify an oxidative
stress indicator that predicts the appearance of
postoperative delirium in patients that undergoes
laparoscopic renal or gynecological surgery for malignant
diseases and the possible correlations between certain
anesthetic drugs and postoperative delirium occurrence.
Sevoflurane is a volatile anesthetic drug used in
many surgical procedures due to its many beneficial
properties. It can be used both in the induction and
maintenance of general anesthesia during surgery.
Propofol is an intravenous anesthetic with known
antioxidant properties that is commonly used for the
induction and maintenance of anesthesia during surgery.
MATERIALS AND METHODS
We enrolled in this prospective study a number of
29 patients that were treated for localized kidney or
uterine cancer by transperitoneal laparoscopic radical
surgery procedures (nephrectomy or hysterectomy)
between 2014 and 2016. They were randomized in two
groups: the sevoflurane group (n=14 patients) and
propofol group (n=15 patients).
All patients enrolled in the study were elderly
patients (age above 65 years), with ASA (American
Society of Anesthesiology) evaluation I-III and
undergoing elective renal or gynecologic laparoscopic
surgery for malignant conditions. Exclusion criteria
included: a history of propofol or sevoflurane allergy,
multiple or severe comorbidities (severe cardiac disease,
severe chronic obstructive pulmonary disease, severe
hepatic disease or severe renal disease), preexistent
cognitive impairment.
The study protocol was conducted in accordance
with the Helsinki declaration (2008) and approved by the
Ethics Committee of the Emergency Clinical Hospital
Craiova. Written informed consent was obtained from
each patient.
All patients had general anesthesia. Patients from
70
both groups were routinely monitored by
electrocardiogram – DII derivation on ECG,
pulsoximetry, capnography, pletismography, blood
pressure, and urine output. All patients were pre-
medicated 1 h before the surgery with midazolam 0.1
mg/kg.
In the sevoflurane group, patients initially
received inhalator sevoflurane for anesthesia induction
started at 8% and gradually decreased until sevoflurane
MAC (minimum alveolar concentration) reached 2-2.5%.
Subsequently remifentanyl 1 µg/Kg over 30-60 seconds
and rocuronium bromide 0.5-0.6 mg/kg was administered
intravenously. Patients were intubated with 7.5-8 mm
cuffed endotracheal tube and ventilated with pressure
ventilation mode: tidal volume 6-8 ml/kg, respiratory rate
12-16 breath/minute, fraction of inspired oxygen 1, with
the aim to achieve a maximum of 45 mm Hg end-tidal
carbon dioxide concentration. Anesthesia was maintained
with sevoflurane 1-1.5 (MAC), remifentanyl 0.05-2
µg/Kg/min and rocuronium bromide 0.1-0.2 mg/kg as
needed. Fluid replacement was performed with 6-8
ml/kg/h of Ringer lactate solution. Extubation was
performed according to Aldrett score. Patients received
postoperative analgesia with morphine intravenous 0.1
mg/kg alternated with paracetamol 1g intravenous
periodically at 6 hours.
In the propofol group, anesthesia was induced
with propofol 2 mg/kg followed by remifentanyl 0.1-2
µg/Kg/min and rocuronium bromide 0.6-0.9 mg/kg.
Patients were intubated and ventilated by same protocol
described above. Anesthesia was maintained with
propofol 0.1-0.2 mg/kg/min, remifentanyl 0.05-2
µg/Kg/min and rocuronium bromide 0.1-0.2 mg/kg as
needed. Fluid replacement, extubation and postoperative
analgesia were performed similarly to the sevoflurane
group. None of patients received anticholinergic drugs at
the time of extubation.
Blood samples were obtained from peripheral
veins preoperatively before anesthesia induction, at the
end of surgery and at 24 hours postoperatively in order to
measure the levels of malondialdehyde (MDA). Blood
samples were separated by centrifugation at 1200 rpm
within 45 min of sampling and stored at −20°C until they
were analyzed. Malondialdehyde was measured by high
performance liquid chromatography (HPLC) with
fluorescence detection. Values were measured as µmol/l
of MDA. Blood samples for superoxide dismutase (SOD)
measurement were immediately stored at 2-8°C until they
were analyzed. SOB was assessed by the photometric
technique (enzymatic method). Values were measured as
U/g Hb.
Postoperative delirium was assessed using
Confusion Assessment Method for the ICU (CAM-ICU)
three times per day immediately after surgery. Delirium
assessment is a part of the overall consciousness
assessment. The consciousness has two parts: level of
consciousness and content of consciousness. Initially the
level of consciousness was assessed by a validated
sedation/level of consciousness scale, such as Richmond
Agitation-Sedation Scale (RASS). Subsequently the
assessment of the content of consciousness, CAM-ICU
Score was performed. Content of consciousness was
assessed only if RASS score is -3 to +4.

Mean and standard deviation values were
determined for all parameters in the two groups. We used
Student's t-test to analyze the differences between
variables in the two groups. P-values of 0.05 or less were
considered statistically significant. Data was analyzed by
MedCalc and SPSS statistical software.
RESULTS
Demographic data for age, height, weight, body
mass index (BMI), sex, living area, are shown in Table 1.
There were no statistically significant differences between
the two groups delirium and non-delirium in both
sevoflurane or propofol patients. (p = ns)
Table 1 Demographic data of patients (data expressed as
mean±SD or percentage)
There were no significant differences among the
delirium or non-delirium groups in sevoflurane or
propofol patients regarding surgery time, heart rate, mean
arterial pressure, end-tidal carbon dioxide, peripheral
oxygen saturation, duration of anesthesia, and
intraoperative complications (p = ns).
All patients with delirium from both groups
developed the condition on the first postoperative day. In
the sevoflurane group, postoperative delirium has
observed in 6/14 patients (42%) and in the propofol group,
5/15 patients (33%) have developed the same
postoperative syndrome. (Table 2)
Table 2: Parameters monitoring perioperative (data
expressed as mean±SD)
For patients that received volatile anesthetic (sevoflurane)
malondialdehyde levels, were significantly increased in
both groups, delirium and non-delirium, at the end of
surgery (7,3±0,8 µmol/l, respectively 8,1±0,8 µmol/l)
compared with those before anesthesia induction (3,3±1,0
µmol/l, respectively 3,0±0,6 µmol/l). Subsequently,
malondialdehyde levels decreased gradually but not
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
significant in both groups postoperatively at 24 hours to
6,3±1,1 µmol/l, respectively 6,0±0,5 µmol/l. In the
propofol group, malondialdehyde levels in non-delirium
group before anesthesia induction were 3,2±0,6 µmol/l
and increased to 5,9±0,7 µmol/l at the end of surgery and
then decreased significantly to 4,5±0,5 µmol/l at after 24
hours after surgery. In the propofol group,
malondialdehyde levels in delirium group before
anesthesia induction were 3,4±0,5 µmol/l, increased to
6,8±0,6 µmol/l at the end of surgery and then decreased
significantly to 5,7±0,8 µmol/l at after 24 hours after
surgery. (Table 3)
Table 3 Malondialdehyde levels (MDA) in the two
groups (data are expressed as mean±SD)
There were no statistically significant
differences between the two groups, regarding
malondialdehyde levels before anesthesia induction. We
recorded a high significant increase of malondialdehyde
levels in the sevoflurane group compared to the propofol
group, at the end of surgery (p<0.01) and 24 hours
postoperatively (p<0.01). There were no statistically
significant differences between delirium group and non-
delirium group in sevoflurane patients, regarding
malondialdehyde levels before anesthesia induction. The
same results were in the propofol group. There was
significant increase of malondialdehyde levels in the
delirium group compared to the non-delirium group in
patients, sevoflurane and propofol, at the end of surgery.
(p<0.05) We recorded a high statistically significant
difference between malondialdehyde levels in the
delirium group and non-delirium group in propofol
patients at 24 hours postoperative. (p<0.01)
Superoxide dismutase levels in the non-delirium
group from the sevoflurane group before anesthesia
induction were 2242,1±94,7 U/g Hb. Superoxide
dismutase levels in the delirium group from the same
sevoflurane group were lower, 2012,7±97,5 U/g Hb. The
SOD levels decreased at the end of surgery for both
groups, non-delirium and delirium, to 1846,4±64,7 U/g
Hb, respectively 1776,5±60,3 U/g Hb, and increased to
2039,4±106,3 U/g Hb, respectively 2062,8±72,9 U/g Hb.
Superoxide dismutase levels in the non-delirium group in
propofol patients before anesthesia induction were
2170,8±98,4 U/g Hb and significant lower in delirium
group from propofol patients, 2004,0±130,0 U/g Hb,
decreased slightly at the end of surgery to 2064,4±56,9
U/g Hb, respectively to 1932,0±103,1 U/g Hb. Superoxide
dismutase levels increased in the non-delirium group to
2108,8±79,5 U/g Hb and in the delirium group to
2064,6±71,7 U/g Hb postoperatively after 24 hours (Table
4).
71
Andreea D. Stanculescu, Dominic G. Iliescu, Octavian Dragoescu, Andrei Drocas, Mihail C. Pirlog, Stefania
Tudorache, Florea Purcaru, Traian Purnichi, Nicoleta A. Dragoescu: Postoperative Delirium Incidence and Oxidative
Stress in Laparoscopic Surgery
Table 4 Superoxide dismutase levels (SOD) in the two
groups (Data expressed as mean±SD)
There were no statistical difference between the two
groups, sevoflurane and propofol, regarding superoxide
dismutase levels before anesthesia induction and at 24
hours after surgery. The results obtained at the end of
surgery in the two groups differed high significantly
(p<0.01). There was statistical difference between
delirium group and non-delirium group in both
sevoflurane and propofol patients, regarding the same
antioxidant marker before anesthesia induction (p<0.05).
We recorded a significant decrease of superoxide
dismutase levels in both groups, delirium and non-
delirium in all patients at the end of surgery, but there was
no statistical difference between the same groups late after
surgery.
DISCUSSION
Postoperative delirium has remained an
important issue for last years because may cause
prolonged hospital stay, postoperative dependence,
increased of morbidity and mortality especially of elderly
people. Delirium develops over a short period of time
(hours to days) after surgery and it is usually reversible.
(15)
There are three subtypes of delirium:
hyperactive, hypoactive and mixed. Hyperactive delirium
is characterized by agitation, patients attempts to remove
tubes and lines. Hypoactive delirium is characterized by
apathy, lethargy and decreased responsiveness. Mixed
delirium is when patients alternate between the two other
forms. (15)
The cause of the high incidence of postoperative
delirium in elderly patients is unclear, but a few
mechanisms were proposed. One proposed mechanisms
was imbalance between oxidative stress and antioxidant
markers levels. (13)
There are only a few researches about
postoperative delirium incidence in laparoscopic urologic
and gynecologic surgery.
Laparoscopic urologic and gynecologic
surgeries are new techniques used for last decades all over
the world for kidney and uterine cancer treatment. The
method is preferred compared to the open surgical
technique due to its multiple advantages. The major
advantage of laparoscopic surgery is less stress than in the
open operative techniques (16)
Operative stress is characterized by oxidative
stress. (17) Laparoscopic surgical techniques, being less
traumatic and less aggressive, are characterized by less
severe oxidative stress than the open surgical techniques
used in renal or gynecological surgeries. (18, 19)
Oxidative stress is the presence of free oxygen
radicals in excess of the buffering capacity of
72
antioxidants. Oxidative stress is an expression of oxidant
and antioxidant biomarkers imbalance. (20) Thus, the
most correct approach for the determination of oxidative
stress is to evaluate and compare the oxidative damage
parameter and the antioxidant parameters. (21)
In this paper, we studied malondialdehyde as an
oxidative stress marker and superodioxide dismutase as an
antioxidant marker, and correlation between that two
markers, anesthetic drugs and postoperative delirium in
laparoscopic surgery for urogenital malign pathologies.
We noticed a lower number of patients with delirium in the
propofol group compared to those in the sevoflurane
group (33% versus 42%)
Malondialdehyde levels had a significant increase
immediately postoperative in the both groups, non-
delirium and delirium, in sevoflurane patients, followed
by a similar decrease in both groups. Similar results were
obtained by Rifat Karlidag et al in their study about
predictors of delirium using preoperative oxidative
processes in patients undergoing cardiopulmonary bypass
surgery, (13)] and Mu-Huo Ji et al in 2013 about the study
on 83 patients with orthopedic surgery procedures and
early postoperative delirium. (22) We noticed that
malondialdehyde levels increases is less significant in the
propofol group than in the sevoflurane group at both
immediate and late postoperative time points.
Superoxide dismutase levels are decreased
preoperatively in all patients that developed delirium in
both sevoflurane and propofol groups, while
postoperative superoxide dismutase levels are
significantly decreased in the sevoflurane group and
slightly decreased in the propofol group for all patients
regardless of delirium development. Superoxide
dismutase levels were increased at 24 hours
postoperatively in all patient groups.
These findings suggest the involvement of oxidative stress
in the postoperative delirium development. Patients with
postoperatory delirium had lower antioxidant protection.
The results confirm the known antioxidant role of
propofol. Our data is in line with the study of Konstantinos
Kalimeris et al. from 2013 that studied the antioxidative
role of propofol vs. sevoflurane upon the postoperative
delirium occurrence in patents with carotid
endarterecomy. (23)
The risk of postoperatory delirium occurrence may
therefore be evaluated by preoperative superoxide
dismutase value. The patients with increased risk for this
syndrome could subsequently avoid it by receiving
postoperative prophylactic low doses of haloperidol that is
the standard treatment of postoperatory delirium.
Furthermore, patients with high risk for postoperatory
delirium may receive before surgery antioxidant agents to
protect them against this syndrome.
CONCLUSION
Significant oxidative stress and antioxidant
activity is proved by the increased malondialdehyde and
decreased superoxide dismutase levels during
laparoscopic surgery for malignant urologic and
gynecologic conditions. Perioperative oxidative stress is
significantly decreased by propofol used in general
anesthesia due to its antioxidant proprieties. Postoperative
delirium incidence can be predicted by preoperative
 Romanian Journal of Psychiatry, vol. XIX, No.2, 2017

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CONFLICT OF INTERESTS A., Ozcan C. The role of oxidative stress in postoperative delirium.
Authors have no conflict of interests to declare. General Hospital Psychiatry 2006; 28: 418 – 423.
14.Choi BH. Oxygen, antioxidants and brain dysfunction. Yonsei Med J
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***

73
CLINICAL CASE
ACUTE PSYCHOTIC EPISODE IN A PATIENT WITH
HIV ENCEPHALOPATHY
Ana-Anca Talasman¹, Alexandra Dolfi2, Mihaela Nae3
Abstract:
We present a case of a 29 year-old man who developed his
first acute psychotic episode in the context of a HIV
infection Stage 3 complicated with leukoencephalopathy.
Both the infection and the cerebral complications were
discovered during his two weeks hospitalization in the
Clinical Hospital of Psychiatry ”Prof. Dr. Al. Obregia”
since January 4th to January 19th 2017, the final
diagnosis being of acute organic psychosis associated to
HIV infection.
The most frequent psychiatric symptoms related to HIV
infection are dementia and depression. Even if secondary
psychosis associated with HIV leukoencephalopathy is not
common, this diagnosis must be taken into consideration
when a psychotic patient presents to the on call room,
especially if risk factors are associated.
Key words: HIV leukoencephalopathy, organic psychosis,
differential diagnosis
BACKGROUND: Psychosis is probably one of the most
intriguing and complex symptom in psychiatry.
Sometimes it's very hard to distinguish between a primary
and a secondary (organic psychosis), especially when the
patient presents with a first psychotic episode and only a
brief examination is made in the on call room. Further
investigations need to be assessed, and differential
diagnosis is of vital importance, mainly because the
prognosis could be very different.
According to the World Health Organization, in the year
2015 36.7 million people were living with HIV virus type 1
worldwide. (1) Because of the progresses made regarding
the antiretroviral therapy, life expectancy of the patients
infected with HIV has increased tremendously in the last
decades. Because of increased life expectancy, clinicians
are more prone to encounter the neuropsychiatric
manifestations of this disease. The most frequent
neurologic manifestations are minor cognitive and motor
disorder and HIV associated dementia, while the most
common psychiatric manifestations are depressive
spectrum disorders. (2) Psychosis is nonetheless an
uncommon but serious complication of infection with
HIV, new-onset psychosis being a possible manifestation
of HIV encephalopathy. (3)
We present a case of a 29 year-old man who developed his
first acute psychotic episode in the context of a HIV
infection complicated with leukoencephalopathy. Both the
infection and the cerebral complications were discovered
1
MD, PhD, Clinical Hospital of Psychiatry “Prof. Dr. Al. Obregia” Bucharest, No.10 Berceni Street, email: anaanca@yahoo.com
2
Resident in Psychiatry, Clinical Hospital of Psychiatry “Prof. Dr. Al. Obregia”, Bucharest, email: dolfialexandra@gmail.com
3
MD, Psychiatrist, Sf. Ioan Clinical Emergency Hospital, naemhl@yahoo.com
Received November 1, 2016, Revised November 16, 2016, Accepted January 9, 2017
74
Rezumat:
Prezentăm cazul unui pacient de 29 de ani care a prezentat
un episod psihotic acut în contextul unei infecții HIV în
stadiul 3, complicată cu leucoencefalopatie. Atât infecția,
cât și complicațiile cerebrale au fost relevate în cursul
spitalizării de două săptămâni în Spitalul Alexandru
Obregia, între 4 și 19 ianuarie 2017, diagnosticul final
fiind de psihoză acută organică asociată infecției HIV.
Cele mai frecvent întâlnite simptome psihiatrice asociate
infecției HIV sunt demența și tulburarea depresivă. Cu
toate că psihoza asociată leucoencefalopatiei HIV nu este
frecventă, acest diagnostic trebuie luat în considerare la
orice pacient psihotic cu factori de risc asociați care se
prezintă la camera de gardă.
Cuvinte cheie: leucoencefalopatie HIV, psihoză organică,
diagnostic diferențial
during his two weeks hospitalization in the Clinical
Hospital of Psychiatry ”Prof. Dr. Al. Obregia” since
January 4th to January 19th 2017, the final diagnosis being
of acute organic psychosis associated to HIV infection.
HISTORY: The patient presented in the psychiatry on call
room for 4 times during three days, being finally admitted
for bizarre behavior, logorrhea and delusion of
persecution. A man who presented himself as patient's
brother brought him to the hospital. We found out a week
later that the man was not his brother, but his partner. The
first psychiatric examination performed in the on call
room revealed polymorphous delusion (grandiose,
prejudice, delusion of being followed and persecution),
elevated mood, suspicion, interpretability and
mannerisms. The rest of the psychic exam was normal.
The psychotic symptoms affirmatively started three weeks
before admission.
The patient had no history of somatic and psychiatric
disorders with no previous hospitalizations. He wasn't
under any medication at home and denied alcohol and drug
abuse. He was living with his life partner, not married,
without children. He was involved in a homosexual
relationship. This fact wasn't mentioned on the admission,
we found out about his sexual orientation during
hospitalisation. Family history: father deceased because of
a colorectal cancer, his mother suffered a stroke and his
brother is suffering from mental retardation.
PSYCHIATRIC EXAMINATION: performed on January
5 2017 revealed a conscious and co operant patient,



oriented in time and space, autopsychic and allopsychic
oriented, visual and psychic contact easily to start and
maintain, expansive mimic and gesture, expressive facies,
spontaneous hyperosexia and no perception disturbances.
The patient presents polymorphous delusion (grandiose,
persecution, prejudice, delusion of being followed)
related to his partner and his medical studies, although ne
never studied medicine: "My partner is a very important
and influent man who is following me and wants to do me
harm; I want to go to Paris for one month, to recover my
immune system and study medicine. Then I will go to
Africa to exchange my appearance and sex. I'm going to
make a research institute for people suffering from
cancer" [...] "I will invest all the money I have into
research. I bought 100 studio flats and tomorrow I'm going
to buy 100 luxury cars". He associates interpretability,
suspicion, accelerated flow and rhythm of speech and
thoughts, elevated mood, mannerisms (extremely polite,
feminine gestures, pretentious use of words and phrases).
Patient's appearance looked clean, hygiene was
maintained, but without attention to small details
(polished but cracked nails, the skin was peeled on his
face). He also presented disinhibited behavior, anxiety,
insomnia, decreased appetite, low activity and no insight.
SOMATIC EXAMINATION: BP 120/80 mmHg, Pulse
100 bpm, onychomycosis on all fingers of both hands,
laterocervical painless and mobile adenopathies, external
hemorrhoids and anal fissures. The rest of the clinical
examination was normal.
PARA CLINICAL EXAMINATION: Abnormal blood
parameters (06/01/2017) leukopenia (2.88 x103/uL) with
lymphopenia (1.24 x103/uL), anemia (RBC 3.31 x106/uL,
HGB 11.2 g/dL, HCT 33.3%), thrombocytopenia (131
x103/uL) and increased erythrocyte sedimentation rate (59
mm/hr). His toxicology urine test was positive for
benzodiazepines. Patient's informed consent was obtained
for syphilis, Hepatitis B, Hepatitis C and HIV screening.
The screening tests for hepatitis B, hepatitis C and syphilis
came back negative, but the rapid screening test for HIV
infection was positive (10/01/2017). It is important to
mention that the patient went to HIV screening two times
the previous year and the screening was negative. His
blood parameters from 2016 were all normal, except for
mild anemia.
His neurological examination was normal, with normal
abdominal echography, normal EKG and hypovoltate
EEG, normal neurosurgical examination. The native
cerebral CT (06/01/2017) showed inhomogeneous density
of the cerebral white matter and cerebral atrophy
incongruous with the biological age. The cerebral MRI
(12/01/2017) showed demyelination bilateral parietal
lesions (FLAIR hyper signal in the parietal white mater,
diffuse, bilateral with no contrast adherence). The
pulmonary Rx showed discrete accentuated interstitial
markings.
COURSE AND TREATMENT: Immediately after
admission, treatment with atypical antipsychotic
(Olanzapine 10 mg/day), anxiolytic (Lorazepam
1mg/day) and mood stabilizer (Sodium Valproate 1000
mg) was started. The next two days patient's evolution was
stationary. He presented logorrhea, with persistent
polymorphous delusion of influence "I can read other
people's thoughts and they can read mine", grandiose and
prejudice "I am gay but very special. I will go to Germany
for an aesthetic surgery to change my face so the others
Romanian Journal of Psychiatry, vol. XIX, No.2, 2017
who want to harm me won't recognize me. When I was
born I died for several minutes and the hospital was
surrounded by tanks and soldiers because my father was a
colonel and a very important man." He was hyper familiar
with the medical personnel, verbally disinhibited,
logorrheic, with elevated mood, anxiety and impaired
insight. His sodium valproate dose was increased to 2
envelopes (2000 mg/day).
In the context of the modified para clinical parameters the
patient did an internal medicine consult and a consult in
the infectious diseases department (10/01/2017) where
Folic Acid 10 mg (2 tablets/day), C vitamin (1g/day),
Cotrimoxazole 480 mg 1 tablet every 12 hours and
fluconazole 200 mg/day were added. The HIV screening
test was repeated in the infectious disease department and
the infection was confirmed (ELISA plus Western Blot
testing). The main indication was to treat the psychotic
symptoms as soon as possible so the patient could be
referred to an infectious disease service, for the treatment
of his HIV infection.
One week after admission, his Olanzapine dose was
increased at 20 mg/day, the sodium valproate dosage was
decreased to 1500 mg/day and Lorazepam was
withdrawn. The treatment was modified because patient's
elevated mood, agitation and anxiety decreased and the
behavioral disinhibition disappeared but the delirium
persisted. Two weeks after admission the polymorphous
delusion also remitted, with slight elevated mood
maintained. The patient regained his insight with
retrograde amnesia of the first week of admission "I know
I had strange thoughts but I can't remember very much. I
know I was thinking that somebody wants to harm me and
I was believing a lot of untrue things ". Before discharge,
patient's insomnia remitted, his appetite increased, the
elevated mood being maintained with slight episodes of
prejudice and grandiose delirium. His reaction to the
unfavorable news of his newly discovered HIV infection
didn't seem to have a big negative effect, although he knew
he was at risk "I didn't know I was infected. My partner
isn't, he keeps doing his tests regularly. I've also done two
tests last year and they came back negative "
Given the favorable evolution under antipsychotic
treatment and the regaining of his insight, after being
informed about the results of his para clinical
examination, the patient was transferred to the National
Institute of Infectious Diseases in order to monitor his HIV
infection. He had the following treatment scheme at
transfer (19/01/2017): Olanzapine 20 mg/day (0-0-1),
Sodium Valproate 1500 mg/day (1/2-0-1), Folic Acid 10
mg/day (2-0-0), Cotrimoxazole 480 mg 1 tablet every 12
hours and Fluconazole 200 mg/day (1-0-0).
The patient was admitted to Matei Bals Institute of
Infectious Diseases between 19/01/2017 and 23/01/2017.
His last blood parameters were: leukopenia with
3 3
lymphopenia (3100 x10 /uL, Ly 1100 x10 /uL ),
3
thrombocytopenia (64 x10 /uL ), CD4=37/mmc,
CD8=158/mmc, hypertriglyceridemia (270 mg/dL),
negative HVB and HVC markers, negative for syphilis,
HTLV and toxoplasma, ARN HIV=472000 copies/mL,
negative Ag HLA B5701. Lumbar punction: clear CSF, 4
elements/mmc, normal biochemistry, negative microbial
cultures, EBV positive.
Discharge diagnoses: Stage C3 HIV infection (new case),
HIV encephalopathy, oral candidiasis, secondary
thrombocytopenia, organic delusional disorder under
75
Ana-Anca Talasman, Alexandra Dolfi, Mihaela Nae: Acute Psychotic Episode in a Patient with Hiv Encephalopathy
treatment, seborrheic dermatitis of the face,
hypertriglyceridemia. In addition to the psychiatric
medication (Olanzapine and Sodium Valproate) which
was not modified, the patient was discharged with
antiretroviral and antibiotic treatment: Darunavir 800 mg
2 tablets/day, Ritonavir 2 tablets/day, Tenofovir 1
tablet/day, Dolutegravir 1 tablet/day, Cotrimoxazole 480
mg 1 tablet every 12 hours, Clarithromycinum 500 mg 1
tablet/day.
Patient's first ambulatory psychiatric examination took
place on 14/02/2017. The psychic exam was normal with
the exception of a slightly elevated mood and
hypersomnia. He he had no delirium, no disturbances of
perception. The patient had insight and was willing to
continue his antiretroviral and psychiatric medication.
The Olanzapine was reduced to 10 mg/day (0-0-1) and the
Sodium Valproate decreased to 1000 mg/day (500 mg
twice a day, 1-0-1). The psychiatric examination on his
next consult (09/03/2017) was completely normal with no
hypersomnia and euthymia, with a very good evolution
both psychiatric and somatic. The favorable evolution
maintained good until patient's last psychiatric consult on
03/04/2017, his final treatment scheme being Olanzapine
10 mg/day (0-0-1) and Sodium Valproate 500mg/day (0-
0-1).
The patient is still psychiatrically monitored every month
and under antiretroviral treatment supervised by the
National Institute of Infectious Diseases.
DISCUSSION: HIV infection produces psychotic
symptoms indistinguishable from those seen in the
functional psychoses. (4) The main particularity of the
case presented above was the similarity with a primary
psychotic episode. What could have been considered to be
a schizophrenia debut was, in fact, an organic psychosis.
The age, the symptoms and the clinical presentation, all
suggested that the patient has a primary delusional
disorder, which could further evolve, in the context of
more following acute psychotic episodes to a diagnosis of
schizophrenia. But his risky behavior raised a big question
mark (multiple partners in the past, involvement in
homosexual relationships) so the para clinical
investigations were continued revealing the diagnosis of
HIV associated encephalopathy, with secondary
psychosis. Other important particularity is the fact that the
patient didn't have any somatic symptoms. The only
anomalies noted on the clinical examination were the
76
lateral cervical bilateral adenopathies and mycosis on all
nails. The blood parameters before admission were
normal except for a mild anemia. In conclusion we had an
atypical debut for HIV infection, with a psychotic episode
with no other clinical or psychiatric symptoms.
The following differential diagnoses were excluded:
Psychotic disorder due to the consumption of multiple
drugs or psychotropic substances, Acute mania with
psychotic symptoms, Serious depressive episode with
psychotic symptoms, Acute polymorphic psychotic
disorder and Delirium. (5) The most frequently observed
symptoms in secondary psychosis are delusions of
persecution or grandeur, or somatic symptoms associated
with visual and auditory hallucinations and changes in the
emotional domain. (5) Our patient only had delusion, with
no somatic symptoms or perception disturbances. He also
had mood changes and disinhibition regarding the
expression of his emotions. There aren't many studies
regarding the antipsychotic treatment in HIV stage 3
associated psychosis, nor established protocols. We chose
to continue the treatment with Olanzapine as the evolution
of our patient was very good and the risk of extrapiramidal
symptoms is low with this antipsychotic. It also helped to
improve patient's low appetite and insomnia symptoms.
CONCLUSION: The most frequent psychiatric
symptoms related to HIV infection are dementia and
depression. Even if secondary psychosis associated with
HIV leukoencephalopathy is not common, this diagnosis
must be taken into consideration when a psychotic patient
presents to the on call room, specially if risk factors are
associated.
REFFERENCES:
1. http://www.who.int/gho/hiv/en/
2. Dubé B, Benton T, Cruess DG, Evans DL. Neuropsychiatric
manifestations of HIV infection and AIDS. Journal of Psychiatry and
Neuroscience. 2005;30(4):237-246.
3. HIV-associated psychosis: a study of 20 cases. San Diego HIV
Neurobehavioral Research Center Group
American Journal of Psychiatry 1994 151:2, 237-242.
4. HIV infection associated with symptoms indistinguishable from
functional psychosis. N Buhrich, D A Cooper, E Freed. The British
Journal of Psychiatry May 1988, 152 (5) 649-653; DOI:
10.1192/bjp.152.5.649 .
5. Calvo-Rivera MP, Porras A, Trigo-Rodríguez M, Martínez-Ortega JM,
Gutiérrez-Rojas L. Psychosis management in patients with hiv: case
report. Actas Esp Psiquiatr. 2017 Mar;45(2):71-78.
***
INSTRUCTIONS FOR AUTHORS
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Manuscripts and all attached files should be submitted in electronic form and on paper.
The electronic form should be submitted, either on compact disk or by e-mail to: aliat@artelecom.net. It is
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The manuscript should be accompanied by a cover letter including:
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Accepted manuscripts become the permanent property of the Romanian Journal of Psychiatry. They may not be
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All named authors should meet the criteria for authorship as stated in the “Uniform Requirements for Manuscripts
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Authors are requested to describe their individual contributions to a study/ paper in a section that will be signed,
attached to and sent together with the “Authorship Responsibilities” form.
Individuals who gave advice on the manuscript should be acknowledged, but are not considered authors.

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If the scientific project involves human subjects or experimental animals, authors must state in the manuscript that
the protocol has been approved by the Ethics Committee of the institution within which the research work was undertaken. A
statement of informed consent for human investigation should be made in the text, along with the name of the institutional
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Submitted manuscripts are screened for completeness and quality of files and will not enter the review process until
all files are satisfactory. The Secretariat will announce the corresponding author about the receipt and the status of the
manuscript.
77
Instructions for authors

A submitted manuscript will be acknowledged and assigned a manuscript number, which is to be used in all further
correspondence. Manuscripts are reviewed and given a priority based on their originality, importance of the findings,
scientific merit and significance for the field, interest to readers, lucidity, and suitability for publication. Manuscripts with
insufficient priority for publication are rejected promptly. Other manuscripts are sent to expert consultants for peer review.
The existence of a manuscript under review is not revealed to anyone other than peer reviewers and editorial staff. Peer
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Corrections

Scientific fraud is rare events; however, they have a very serious impact on the integrity of the scientific
community. If the Editorial Board uncovers possible evidence of such problems it will first contact the corresponding author
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the Board will contact the appropriate official(s) in the institution(s) from which the manuscript originated. It is then left to
the institution(s) in question to pursue the matter appropriately. Depending on the circumstances, the Romanian Journal of
Psychiatry may also opt to publish errata, corrigenda, or retractions.

Manuscript Preparation

Romanian authors should send both the Romanian and English version of the article, including title, abstract and
key words. Foreign authors should send the English version of the article.
Manuscripts must be prepared in conformity to the “Uniform Requirements for Manuscripts Submitted to
Biomedical Journals: Writing and Editing for Biomedical Publication” issued by the International Committee of Medical
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Articles must be written in Microsoft Word, Style: Normal + Justify, Font: Times New Roman, size 12. All
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78
 Romanian Journal of Psychiatry, vol. XIX, No.1, 2017

acknowledgements.
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Abbreviations.

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Vraşti R, Matei VMI. The crisis centre in Romania. Eur J Psychiat 2002; 29:305-311.
Reynolds CF, Frank E, Perel JM et al. Treatment of consecutive episodes of major depression in the elderly. Am J
Psychiat 1994; 151(12):1740-3.
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Vrasti R. The crisis centre in psychiatry. Toronto, London: Academic Press, 1993, 26-52.
- Reference to a chapter in an edited book:
Schuckit MA. Alcohol-Related Disorders. In: Sadock BJ, Sadock VA, Ruiz P (eds). Comprehensive Textbook of
Psychiatry. Philadelphia: Lippincott Williams and Wilkins, 2009, 1268-1287.
The placement of the italics, punctuation and the general aspect of the text format must comply with the rules
mentioned above. This is a mandatory and eliminatory condition.

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VERY IMPORTANT: All manuscripts intended for publication will be subject to peer-review by a committee of
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professional translator.

79
Instructions for authors

Address to send the manuscripts is:

REVISTA ROMÂNĂ DE PSIHIATRIE

ASOCIAŢIA ROMÂNĂ DE PSIHIATRIE ŞI PSIHOTERAPIE
Prof. Dr. Dan PRELIPCEANU
Clinical Hospital of Psychiatry “Prof. Dr. Alexandru Obregia”
Şos. Berceni 10, sector 4, 041914 Bucureşti
Tel./Fax: +40-21-334.84.06
E-mail: aliat@artelecom.net

Contact: Viorel Roman – web editor

E-mail: aliat@artelecom.net
Tel. +40-21-334.84.06

www.e-psihiatrie.ro/revista - print edition

www.romjpsychiat.ro - online edition

80
 ROMANIAN JOURNAL
OF PSYCHIATRY
CONTENTS

EDITORIAL EDITOR-IN-CHIEF: Dan PRELIPCEANU

CO-EDITORS: Dragoş MARINESCU
Aurel NIREŞTEAN
& Burnout Syndrome 33
Dan Prelipceanu, Raluca Barbu ASSOCIATE EDITORS:
Doina COZMAN
SPECIAL ARTICLES Liana DEHELEAN
Marieta GABOŞ GRECU
Maria LADEA
& ABB - Norwegian Criminal. Psychosis vs Psychopathy - Cristinel ŞTEFĂNESCU
Psychiatric Forensic Analysis 36 Cătălina TUDOSE
Gabriela Costea
Executive editor: Valentin MATEI
REVIEW ARTICLES STEERING COMMITTEE:
Vasile CHIRIŢĂ (Honorary Member
& Genetics of Alcohol Use Disorder 48 of the Romanian Academy of
Maria Bonea, Ioana V. Micluţia Medical Sciences, Iaşi)
Michael DAVIDSON (Professor, Sackler
& Psychosocial Factors Influencing Asperger Disorder 52 School of Medicine Tel Aviv Univ.,
Mihai Gabriel Alin Șuiu Apostol, Oana Boantă, Mihnea Manea, Mount Sinai School of Medicine,
Iuliana Dobrescu New York)
Virgil ENĂTESCU (Member of the Romanian
Academy of Medical Sciences, Satu
ORIGINAL ARTICLES
Mare)
Ioana MICLUŢIA (UMF Cluj-Napoca)
& Elevated Plasma Fibrinogen a Possible Biomarker for Psychological Şerban IONESCU (Paris VIII Universiy, Trois-
Distress and Depression 55 Rivieres University, Quebec)
Traian Purnichi, Gabriela Puiu, Ileana Marinescu, Mihail C. Pîrlog, Mircea LĂZĂRESCU (Honorary Member of the
George Paraschiv, Silvia Ristea, Ruxandra Banu, Ioana G. Pavel, Romanian Academy
Mihai Bran, Lavinia Duică, Ruxandra Grigoraș, Valentin P. Matei of Medical Sciences, Timişoara)
Juan E. MEZZICH (Professor of Psychiatry
& Factors Associated with Medication Adherence in Patients with and Director, Division of Psychiatric
Schizophrenia 59 Epidemiology and International
Ana M. Romoșan, Felicia Romoșan, Liana Dehelean, Mihaela A. Simu, Center for Mental Health, Mount
Virgil R. Enătescu, Cristina A. Bredicean, Ion Papavă, Iris Druț, Sinai School of Medicine, New York
Mihaela O. Manea, Ioana Riviș, Simona D. Rădulescu, Radu Ș. Romoșan University)
& Metabolic Assessment and Quality of Life in a Sample of Patients in Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Treatment with Olanzapine Depot 65
Department of Psychiatry,
Ana-Anca Talașman, Mihaela Nae, Alexandra Dolfi,Irina Luca, University of Maryland School of
Mihai V Zamfir Medicine, Baltimore)
& Postoperative Delirium Incidence and Oxidative Stress in Laparoscopic Sorin RIGA (senior researcher)
Surgery 69 Dan RUJESCU (Head of Psychiatric Genomics
Andreea D. Stanculescu, Dominic G. Iliescu, Octavian Dragoescu, Andrei and Neurobiology
and of Division of Molecular and
Drocas,Mihail C. Pirlog, Stefania Tudorache, Florea Purcaru, Clinical Neurobiology,
Traian Purnichi, Nicoleta A. Dragoescu Department of Psychiatry, Ludwig-
Maximilians-University, Munchen)
CLINICAL CASE Eliot SOREL (George Washington University,
Washington DC)
Maria GRIGOROIU-ŞERBĂNESCU
& Acute Psychotic Episode in a Patient with HIV Encephalopathy 74 (senior researcher)
Ana-Anca Talasman,Alexandra Dolfi, Mihaela Nae Tudor UDRIŞTOIU (UMF Craiova)

APR
INSTRUCTIONS FOR AUTHORS 77

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