EBOOK - D508 - 3rd Psychiatry - Galatia-3

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PROCEEDINGS
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EUROPEAN CONFERENCE OF
PSYCHIATRY AND MENTAL
HALTH
(Galatia, 8-12 May 2019)
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INDEX
Foreword 8
Anxiety – Therapeutic Options from Past to Present 10

MANEA Mirela, CIOBANU Adela Magdalena, MANEA Mihnea Costin
Sexual Functioning in Schizophrenic and Bipolar Female Patients 16

MICLUŢIA Ioana Valentina, DAMIAN Laura, ŞERBAN Ana Cristina
The Importance of the Supportive Psychotherapy for the Cancer Patients

and their Families 22
NEAGA Susanu
Self-perception and Eating Behaviour in Obesity and Diabetes 28

MOROȘANU Andreea, MOROȘANU Magdalena, CLINCIU Aurel Ion
From Depression to Human Immunodeficiency Virus – A Case Report 34

SAPIRA Violeta, LUNGU Mihaiela, TELEHUZ Anca
Psychiatric Disorders Associated with Endocrine Dysfunctions 39

CHIRITA Anca Livia, POPESCU Mihaela, CALBOREAN Veronica,
GHEORMAN Victor, UDRISTOIU Ion
General Nutrition Principles for the Mental and Physical Health of Children 46
LUPU Vasile Valeriu, MIRON Ingrith, NISTOR Nicolai, STARCEA Magdalena,
LUPU Ancuta, CIUBARA Anamaria
Sexual Dysfunctions in Schizophrenia – A General Overview of

Relevant Clinical Symptoms 52
MORARU Codrina, RĂDULESCU Ionuț-Dragoș, ROȘU Ioana,
NECHITA Petronela, CIUBARĂ Anamaria
Eating Disorders Associated with Mood [Affective] Disorders 56

DAMIAN Maria-Cristina, TERPAN Mihai, CIUBARĂ Anamaria
Anniversary Depression 61
MUSCĂ Loredana-Maria, PLEȘEA-CONDRATOVICI Cătălin,
CIUBARĂ Anamaria
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Dreaming and Parasomnias from a Cerebral Structural View 69

ELKAN Eva-Maria, PAPUC Ana-Maria, GOROFTEI Roxana Elena Bogdan,
BANU Elena Ariela, ZLATI Monica, ALBEANU Adriana Gabriela,
CONDRATOVIC Alina Pleșea
The Identity of the Psychiatric Patient – Between the Narrative Self

and the Experiential Self 74
VOINEA Alina-Ioana, DOBRI Mirona-Letiţia, ROŞU Ioana,
Falsification and Counterfeiting of Pharmaceutical Products. Poisoned Elixir –

Illegal Contamination of Food Supplements Recommended in Obesity Control 81
OVIDENIE Cristina-Elena, LISĂ Elena-Lăcrămioara
Dual Diagnosis. Alcohol Consumption Associated with

Depressive Spectrum Disorders 87
DARIE Cristina, TERPAN Mihai, SARBU Fabiola, CIUBARA Anamaria
Pharmacological Add-On Treatments in Managing Antipsychotic-Induced

Weight Gain 93
RĂDULESCU Ionuț-Dragoș, MIRONA Letiția Dobri, MORARU Codrina,
NECHITA Petronela, CIUBARA Anamaria
Mindfulness: A Psychotherapeutic Method of Acceptance and Centering

of the Mental Framework 102
DOBRI Mirona Letitia, VOINEA Alina-Ioana, RĂDULESCU Ionuț-Dragoș,
Psiho-Oncologia. Case Presentation 108

PÂSLARU Ana Maria, FĂTU Ana Maria, SÂRBU Fabiola,
NECHIFOR Alexandru, REBEGEA Laura, CIUBARĂ Anamaria
Burnout Syndrome at the Anaesthesia & Intensive Care and Surgical Unit’s
Medical Personnel within Emergency Clinical Hospital of Galati – Original Study 113
MANOLE Corina, CIUBARĂ Anamaria, FIRESCU Dorel, ŞERBAN Cristina,
ŢOCU George
The Prevalence of Cognitive Impairment in Patients with Proximal Femoral Fractures 119
GOGULESCU Bogdan Adrian
Burnout Risk Evaluation in Medical Oncology – Radiotherapy Personnel 128

REBEGEA Laura, TARLUNGIANU Camelia
The Prevention of Dementia Before and After Stroke 135

FĂTU Ana-Maria, PÂSLARU Ana-Maria, SÂRBU Fabiola,
CREANGĂ-ZĂRNESCU Valerica, CIUBARĂ Anamaria
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Factitious Disorders – Challenges in Psychiatric Diagnosis 140

ROSU Ioana, VOINEA Alina Ioana, NECHITA Petronela,
CIUBARA Anamaria
Trends in the Treatment of Patients with Disorder Linked with Alcohol

and Associated Depressive Disorders 146
SÂRBU Fabiola, TERPAN Mihai, CATANA Simona Cristina,
CIUBARĂ Anamaria
Peculiarities of Depressive Disorder in Elderly Patients 152

SARBU Fabiola, CORBEANU Dan-Constantin, CIUBARA Anamaria
Comparative Assessment of Community-Based Mental Health Services (CBMH)

in 4 Pilot and Mon-pilot Districts after the 1st Phase of the Reform of
Mental Health System in the Republic of Moldova 156
CHIHAI Jana
Autism Spectrum Disorders (ASD) and Rare Genetic Diseases in the Republic
of Moldova: The Needs of Children with ASD And Genetic Diseases and of their
Parents/Caretakers for Medical, Social and Educational Services 163
CHIHAI Jana, ADEOLA Cornelia, BOLOGAN Alina,
RADISLAV Cosulean
Complications of Hips Hemiarthroplasty at Pacient with Dementia 169

BRADEANU Andrei Vlad, PASCU Loredana, CIUBARA Alexandru Bogdan,
VOICU Dragos Cristian, CIUBARA Anamaria
Work-related Temporomandibular Joint Disorders and Cognitive Behavioural

Therapy in Dental Medicine Practitioners 173
CHECHERIȚĂ Laura Elisabeta, CĂRĂUȘU Elena Mihaela,
BURLEA Lucian Ștefan, LUPU Costin Iulian, STAMATIN Ovidiu,
CIUBARA Anamaria
The Value of Cognitive Therapy in the Treatment of Dental Phobia 180

STAN Dorina, VOICU D.F.
Ketamine in Perioperative Depressive Symptoms (PDS) Improvement –

Review 184
MANOLE Corina, SERBAN Cristina, CIUBARA Alexandru Bogdan,
CIUBARA Anamaria
Social Media Addiction in Adolescents and Young Adults –

Psychoeducational Aspects 188
LUCA Liliana, CIUBARA Alexandru Bogdan, ANTOHE Magda Ecaterina,
PETERSON Ioana, CIUBARA Anamaria
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The Link Between Lipidic Profile, Depression and Cardiovascular Disease 192
ANGHEL Lucretia, URSU Dumitru, BAROIU Liliana
The Role of Polyunsaturated Fatty Acids in Neurocognitive Development

in Children 196
TRANDAFIR Laura Mihaela, INDREI Lucian Laurențiu, STÂRCEA Magdalena,
MIRON Ingrith
Supraclavicular and Cervical Lymph Node Metastases Having Cervical Cancer

as Starting Point – Case Presentation 201
PÂSLARU Ana-Maria, NICULEȚ Elena, REBEGEA Laura, TUTUNARU Dana,
CIUBARĂ Anamaria
Polyradiculoneuritis in an Adolescent after Acute Pneumony 208

JESCU Teodora, MIRON Ingrith, LUPU Vasile Valeriu, MOISA Stefana,
POSTOLACHE Anca, MIRON Oana Tatiana, LUPU Ancuta
Difficulties in the Therapeutic Management of Complicated Pneumonia

in Children 213
MIRON Oana, IVANOV Anca, MOCANU Adriana, STÂRCEA Magdalena,
TRANDAFIR Laura, MIRON Ingrith
The Onset of Dementia Through the Cotard Syndrome – The Delirium

of Negation 223
DARIE Cristina, CIUBARA Anamaria
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THE EDITORIAL BOARD FOR THIS ISSUE
Editor in Chief:
Prof. Anamaria Ciubara (Romania)
Members:
Prof. Giangennaro Coppola (Italy)
Prof. Mendo Castro Henriques (Portugal)
Prof. Salvatore Vendemmia (Italy)
Prof. Dan Gabriel Simbotin (Romania)
Prof. Michael Davidson (USA)
Associate Prof. Olga Vascovic (Serbia)
Associate Prof. Alexandru Bogdan Ciubara (Romania)
Lecturer Bogdan Patrut (Romania)
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FOREWORD
3rd European Conference of Psychiatry and Mental Health “Galatia” 2019 took place during the
period 8-12 May 2019 under the aegis of “Dunarea de Jos” University, Romanian Academy and
Romanian Minister of Health. The Event has more than 800 participants that has activity on
Psychiatry and connected fields. A total of 423 abstracts were applied. From these abstracts 124
papers were selected to be presented oral or poster at the Conference. After the per-review process
(double blind), only 37 papers have been proposed to be published and indexed in the Proceedings
Issue of the Conference. All the person that participate to the per-review Process are specialist in
the field of the paper evaluated and they are members in the Editorial Board or Per-review team of
the indexed (WoS) journals.
President of 3rd European Conference of Psychiatry and Mental Health “Galatia” 2019,
Hab. Professor Dr. Anamaria Ciubara, MD, PhD
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Anxiety – Therapeutic Options from Past to Present
MANEA Mirela1, CIOBANU Adela Magdalena2, MANEA Mihnea Costin3

1 M.D. Senior Psychiatrist at Clinical Hospital of Psychiatry “Prof. Dr. Alexandru Obregia”, PhD, Professor “Carol Davila”
University of Medicine and Pharmacy Bucharest (ROMANIA)
2 M.D. Senior Psychiatrist at Clinical Hospital of Psychiatry “Prof. Dr. Alexandru Obregia”, PhD, Associate Professor “Carol
Davila” University of Medicine and Pharmacy Bucharest (ROMANIA)

3 M.D. Psychiatrist at Clinical Hospital of Psychiatry “Prof. Dr. Alexandru Obregia”, PhD, Lecturer “Carol Davila” University
of Medicine and Pharmacy Bucharest (ROMANIA)

Email: mirelamanea2003@yahoo.com
Abstract
Anxiety is a diffuse fear of an object, rather potential than present, it is detached from concrete
and projected in the future. It associates psychomotor restlessness and has neurovegetative
response. Anxious symptoms create a discomfort that patients experience with great difficulty.
Whether we are talking about generalized anxiety, or we are talking about anxious paroxysms,
patients call for help, sometimes in Emergency Room (ER) because of irrational fear of death, or
fear of madness. The anxiety disorder is common in all medical healthcare offices, but especially
in psychiatry. The therapeutic attitude is based on the same principles everywhere, but there are
situations in which the treatment differs and psychotic anxiety, the particular form requiring
admission into specialized service, is under discussion here. If in the past, the first intention was
benzodiazepine (BZD) anxiolytics at the moment, they are increasingly finding their place in the
therapeutic scheme. The beneficial effect installs quickly, but when balancing the balance versus
risk, balances often tends to overcome the anxiolytic classics. Nowadays, more frequently,
protocols recommend administering SSRI antidepressants to treat anxiety. In the case of emergency
in which anxiety occupies a main place, such as psychotic anxiety, it is necessary to prescribe
antipsychotics, especially atypical antipsychotics. For these reasons, we aim to share our
experience for patient benefit.
Keywords: anxiety, anxiety paroxysms, benzodiazepine anxiolytics, SSRI antidepressants
Introduction
Anxiety disorders are commonly medical conditions, in general medical practice and more
frequently in psychiatry practice. They include a wide range of symptoms requiring treatment due
to their disabling potential. Anxiety is perceived as “fear without object”. [1, 2] Normally anxiety
occurs as a transient response to new experiences, spent or anticipated changes if, or under stress.
In these situations, it is a factor of progress, making it possible to successfully overcome the
moment. Anxiety with clinical significance is an inadequate response to a given stimulus or just
anticipated whether it is real or imaginary. From the clinical point of view, there is no external
stimulus objectively triggered in causing anxious symptoms. However, the experiences are
persistently intense, which determine anxious behaviour avoidance or social withdrawal. The
prevalence of anxiety disorders worldwide is increased without having the right data due to sub
diagnostics and the lack of correct mapping. According to the Epidemiological Catchment Area
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(ECA) study conducted by the National Mental Health Institute of the U.S. (National Institute of
Mental Health) lifetime prevalence of anxiety disorders is 14.6% and one year is 12.6%. [3] Also
in the U.S. the magnitude of the phenomenon has been measured between 1990 and 1992 and the
National Comorbidity Survey (NCS) has determined that the prevalence of anxious conditions was
25%, with a gender distribution of 19% for men and 33% for women. [3]
Clinically, two major elements of anxiety disorders are described: psychiatric manifestations
and somatic manifestations.
Psychiatric manifestations include anxious symptoms in which anxiety, fear without cause and
worry are the essential elements in establishing the diagnosis. Concern is perceived as a high
negative potential. Sometimes the intensity of symptoms is elevated, which will cause paroxysms
that can be felt as an imminent death sensation, or the fear of madness. Along with the anxiety
component there is also described the cognitive component, which is responsible for lowering the
attention concentration capacity, but with selective voluntary hyperpyrexia, short-term memory
difficulties. From the somatic point of view, anxiety disorders may occur: dizziness, sweating,
diarrhoea, palpitations, tachycardia, psychomotor restlessness, hypertension (HTA) paroxysms,
especially paraesthesia of the limbs, tremor and nodule in the throat. Physical symptoms occur
repeatedly and they are not subject to voluntary control, they are not simulated and cannot be
deliberately determined. Concerned about the functioning of his or her body, the anxious patient
checks his pulse, checks the appearance in the mirror, and facies express fear, terror, terror. It can
often associate the feeling of suffocation, the impression that the heart can stop from one moment
to the next, pain in various areas of the body, often abdominal and sweating. Trying to systematize
the generalized anxiety in main and secondary symptoms, the first category includes the inability
to relax, restlessness, fatigue, disproportionate responses, muscle tension, sleep disruptions,
difficulty concentrating, irritability, and in second nausea or abdominal pain, sweating, dry mouth,
tachycardia and their perception as palpitations, tremor. [4]
Management of Anxious Disorders
The anxiety symptoms are so invaliding to disrupt the life and activity of any person.
Suffering causes avoidance of any situation or place that may be related to triggering any anxiety
disorder. Sometimes patients with anxious complain consider somatic symptoms to be caused by
a serious risk of vital illness such as myocardial infarction. The therapeutic intervention is required;
it has been a therapeutic priority long before. The way to initiate a therapy differs over time. In the
1980s, anxiolytics were recommended in “moderate doses” for 2-4 weeks. [5, 6] The
recommendation was for benzodiazepine anxiolytics: diazepam, medazepam, hydroxyzine but also
chlordiazepoxide, opipramol, amobarbital sodium in combination with various other substances.
Introduced into medical practice for over 50 years their use has gained a great deal. This is due
to the rapid response and improvement of symptomatology and good tolerability. Initially called
tranquilizers, later known as anxiolytic, ataractic, were recommended for the treatment of neurotic
states, and they were accredited with the installation of psychic, somatic and vegetative serenity.
Tranquilizers/anxiolytics are a pharmacological class that includes groups of drugs whose
principal psychopharmacological action determines: diminishing anxiety, reducing mental state,
controlling excitement states – psychomotor agitation, also improving behavioural disorders,
balancing emotional reactions, but also other effects: myorelaxant, anticonvulsant and
antihistamine, secondary benefits of blockade of beta-adrenergic receptors. [10]
In previous classifications, anxiolytic medication was framed in minor tranquilizers that were
differentiated by major tranquilizers that included classical neuroleptics. [7] Nowadays there are
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several types of substances that have the main anxiolysis effect, and the most commonly used are
benzodiazepines (BZDs). Besides these, they include the following subclasses:
Azospirodecandions (Buspirona), Carbamates (Meprobamate), Beta-blockers (Propranolol),
GABA transporter inhibitors (Tiagabine), other tranquillizing or anxiolytic agents, Sedative
antihistamines Benzodactamine (Tacitine), barbiturates that also have hypnotic, anxiolytic and
anticonvulsant effect, other psychotropic drugs: sedative neuroleptics, antidepressants, anxiolytics.
[10]
Benzodiazepines have been widely prescribed since the 1960s to 1980s for anxiety disorders by
psychiatrists, family physicians, internists, because the level of knowledge shows that the efficacy
is good, the tolerability is good, with a high degree of safety, compared to other anxiolytics such
as barbiturates and meprobamate. [11] Retail sales of benzodiazepines reached a maximum of 87
million/year in 1973-1975, and the US has the largest sales volume in the world. If diazepam
initially occupied the primary site, over the course of time, sales of short-chain elimination half-
drugs (alprazolam) increased compared to long-acting drugs (diazepam). [10] In the 1990s, there
was a shift in the share of sales in the sense of their growth in favour of SSRIs (selective serotonin
reuptake inhibitors), which became the main therapeutic alternative to anxiety disorders. In the
USA. between 1979 and 1990 the consumption of benzodiazepines fell from 11.1% to 8.3%. (11)
Initially, the mode of action of benzodiazepines was not known, and it began to be elucidated
after 1977 when the benzodiazepine receptors, the Central Nervous System (CNS) GABA
receptors, were discovered. Currently, there are three types of GABA receptors: GABA-A, GABA
B and GABA C. In addition to these receptors involved in anxiety, alpha-2-delta (α2δ) ligands have
also been shown to play an important role in blocking glutamate release. As substances involved
in subunit (α2δ) binding are pregabalin and gabapentin. [13]
Pharmacologically it is determined by its action by improving the GABA-ergic transmission by
blocking the GABA-A receptors/Cl ion channels. Receptor blocking causes the ion channels of Cl
to open and penetrate into the cell. BZD activates all three GABA-A receptor binding sites and in
this way determines the anxiolysis effect. The use of benzodiazepine anxiolytics in the management
of anxiety disorders is due in particular to their mode of action, starting from their structural
characteristics and in vivo behaviour. The pharmacokinetic characteristics guide the clinician in
their use. There are differences in intestinal absorption, distribution and elimination. The
absorption rate is high in the digestive tract, those that are rapidly absorbed enter faster in action
than those with slower absorption. Diazepam is one of them. Absorption after intramuscular
injection is due to other factors. An example of lorazepam has good absorption rates in both
administrations whereas chlordiazepoxide has much better oral absorption than in the injectable
form liposubility is another factor to be considered. Thus, at a physiological pH BZD passes the
blood-brain barrier through diffusion determines the rapidity of the effect, but also its intensity.
Diazepam is rapidly absorbed, being more liposoluble, reaching its maximum blood
concentration after approximately one hour, but lorazepam has the intermediate absorption rate.
[12]
Depending on all the data outlined above, there are advantages and disadvantages in the use of
the benzodiazepine anxiolytics used. Substances with short half-life have the following advantages:
along with anxiety reduction, rapid action, especially in anxious paroxysms, low sedation, lack of
accumulation in the body, and the possibility of administration to the elderly, but with caution.
Disadvantages include: multiple dose administration, faster deployment of addiction syndrome,
rebound insomnia, and anterograde amnesia, which may precipitate the onset of cognitive
impairment. [11]
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The other type of benzodiazepines with longer half-life has, besides the anxiolytic effect, the
benefit of less frequent administration, less frequent dosing, much lower fluctuations in plasma
concentrations, less frequent depression, and less severe abstinence symptoms. Disadvantages are
also present in these substances: the risk of drug accumulation, the greater possibility of
psychomotor disorders during the day and the occurrence of diurnal sedation with its whole follow-
up corollary.
Administration of benzodiazepine anxiolytics between benefit and risks. Anxiolysis in anxiety
disorders is the main effect, which has led to their excessive use especially in the second part of
the last century. The research that has been carried out and the data behind them reveal a number
of side effects that make us wonder: is it worthwhile taking the risk of side effects? Every time we
initiate a therapy, we have to balance it to what it is: to the potential therapeutic efficacy, or to the
risks of adverse effects? We have tried to identify the most common adverse effects, but also to
draw attention to the particular ones that may occur in various categories of affections or patients.
The most common risk is the abuse of substances, the possibility of installing dependence on
the entirety of symptoms. Then excessive sedation often occurs with daytime somnolence, which
is why drivers and those who carry out activities requiring motor coordination should be warned.
There is a possibility of detection state of residual daytime sedation even if benzodiazepine
anxiolytics were given the night before. In the case of the elderly, there is the possibility of
installing delirium, especially in case of administration of substances with long half-life, the
possibility of triggering the cognitive disorder with amnesia fixation, confusing state. Aging and
vertigo may also occur in the elderly, which may cause accidental fractures and fracture of the hip.
As described effects: muscle hypotonia, fatigue, nystagmus, dysarthria, headache, somatic
disorders such as respiratory, sleep apnoea, administration of these substances is contraindicated
in decompensated liver disease; administration is prudent and at low doses due to the risk of
inducing hepatocellular carcinoma. The teratogenic risk, the new-born’s reaction to breastfeeding
after benzodiazepines, is also quoted. Neurological disorders due to stroke after vascular accidents
usually have minimal recommendation for treatment with anxiolytic agents due to the possibility
of triggering paradoxical effects with agitation and extreme aging. In the case of affective disorders,
the administration of these benzodiazepines may lead to manic reversal in the case of depression,
or even more importantly, the risk of suicide may be triggered by triggering the suicidal ideation.
[10, 11, 14, 15]. Another important thing is the risk of associating alcohol consumption with
anxiolytic medication due to the risk of substance abuse, but also by respiratory distress,
disinhibition, then marked sleepiness.
If the first intention treatment recommendation in the 1970s was anxiolytics, especially
benzodiazepines, towards the end of the 20th century they are being used in combination with
tricyclic antidepressants, namely imipramine or clomipramine. [8, 9]
At present, the management of anxiety from a psychopharmacological point of view requires a
more complex approach, due to scientific arguments resulting from clinical trials, the
argumentation of the neurotransmitters involved, clinical efficacy, but also latency until the
therapeutic response is established. Anxiety disorders, whether we are talking about generalized
anxiety disorder, panic disorder, posttraumatic stress disorder, other reactions to severe stress, have
first-line recommendations for SSRIs or SNRIs before benzodiazepines to which buspirone and
α2δ ligands can be associated. [13, 16] Here are quoted opinions on the use of benzodiazepine
anxiolytics due of the risk of addiction, given that generalized anxiety disorder, for example, is a
chronic disease and requires long treatment. Regarding the therapeutic attitude for chronic,
recurrent anxiety, antidepressants are the first choice, the other psychotropic drugs are used only
as adjuvant medication to augment the effect of antidepressants. The most recommended are SSRIs
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and SNRIs for the most common type of anxiety disorders. [17] Similarly, the therapeutic attitude
of other authors, [18] recommends first-line SSRI medication, which are more effective than
alprazolam and imipramine in the treatment of anxiety. Doses will be customized by each patient
and the type of anxiety disorder.
As a conclusion of all the above, it results that in recent years solid arguments have emerged in
dethroning benzodiazepines from the first therapeutic line and passing them to the second place as
associated medication. In this context, the SSRI antidepressant medication becomes the first
choice. Although they act slower on anxiety symptoms, they are better tolerated in the longer term,
with long-term efficacy, and for each type of anxiety disorder, the FDA recommends a certain
substance [13]. The FDA guidelines for treatment of anxiety disorders are: generalized anxiety –
escitalopram, panic disorder – fluoxetine, social anxiety disorder – fluvoxamine, GAD, PTSD –
paroxetine. SNRIs are also a therapeutic alternative, so venlafaxine has FDA recommendation for
generalized anxiety disorder, panic disorder, and social anxiety. With regard to Duloxetine, it has
an indication from the FDA for generalized anxiety disorder. [13]
As with benzodiazepines, SSRI and SNRI antidepressants are advantages and disadvantages
when used. Advantages include the following: lasting efficacy in all anxiety disorders, overdose
safety, low weight gain, no risk of addiction. Concerning the drawbacks, it should be mentioned
that the slow, delayed onset of the therapeutic effect may initially cause anxiety, gastritic side
effects may occur at initiation of treatment, and sexual dysfunction throughout treatment. [3]
Conclusions
In conclusion, we can state that a correct assessment should be made with the discovery of the
possible therapeutic emergencies in which the main element is anxious paroxysms. The therapeutic
attitude in the case of anxiety disorders depends on each individual patient, and the initiation of the
treatment must take into account the intensity of the symptoms, the mode of action of each
psychotropic used, the correct assessment of the benefit versus risk balance.
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15. Sadock, B., Sadock, V., Kaplan & Sadock Terapie Medicamentoasa in Psihiatrie, Ed. Callisto 2002, pp. 63-
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Nine Edition, Lippincott Williams & Wilkins, 2009, pp. 1906-1914.
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a metanalysis. Int. Clin. Psychopharmacol. 10, 1995, pp. 45-49.
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Sexual Functioning in Schizophrenic and Bipolar Female Patients
MICLUŢIA Ioana Valentina1, DAMIAN Laura2, ŞERBAN Ana Cristina3

1 University of Medicine & Pharmacy “Iuliu Haţieganu” Cluj-Napoca, department of Neuroscience, discipline of Psychiatry,
Emergency County Hospital Cluj, Second Psychiatric Clinic, 43 Victor Babeş str. 400012 Cluj-Napoca, (ROMANIA)
2 Chronic Hospital Cluj “Ergoterapie”, 126 Decebal str., 40056 Cluj-Napoca, (ROMANIA)
3 Emergency County Hospital Cluj, 43 University of Medicine & Pharmacy “Iuliu Haţieganu” Cluj-Napoca, Romania, PhD
student (ROMANIA)
Email: ioanamiclu@yahoo.com
Abstract
Introduction
The issue of sexuality is seldom investigated by psychiatrists in psychotic psychiatric patients,
partly due to the frontline distressing psychiatric and behavioural symptoms but also due to
hesitancy, haste, reluctance. Even though, the aspects of intimacy, sexual functioning are important
and bothering, especially for young patients. These sexual impairments might be attributed to the
disease itself but also to the medication.
Material and Methods

Two separate studies aim to investigate sexual disorders in female inpatient patients diagnosed
with schizophrenia and in different phases of bipolar disorder (depression, manic) in comparison
to controls. Therefore, treatment emergent sexual side effects (UKU scale), their relation to
psychopathology (PANSS, GAF), quality of life (WHO-QOL Bref), misbelieves (Sexual
Dysfunctional beliefs Questionnaire) were explored in chronic female schizophrenic patients and
compared to matched controls. For the bipolar group, the depressed, manic women and controls
were assessed regarding frequency of sexual intercourse, fantasies, desire, and lubrication orgasm
by the Sexual Disorders Interview, Female Sexual Index and psychopathology by BDI,
respectively YMRS. Both studies were cross-sectional and collected various demographical and
therapeutical data.
Results
Schizophrenic patients rendered long histories of the disease and treatments, cumulating also
disturbing side effects such as weight gain, amenorrhea, less marital and sexual partners. Low
sexual interest, modest initiative, involvement, absent orgasm and sexual conservatorism were
common and constant during exacerbations but also in chronicity being in connection rather to
negative symptoms and modest functioning. With regard to bipolar women, sexual problems were
detected in over 75% of the cases, with less implication and satisfaction during depression, pain,
blaming often antidepressants as probable source of dissatisfaction. On the other hand, manic
patients display more vivid sexual fantasies and interest, with higher arousal and lubrication,
attending sexual satisfaction but being disturbed subjectively by some of these aspects. Although
a wide range of sexual disorders might arise after treatment with antipsychotics, antidepressants,
mood stabilizers, there could not be clearly ascertained a specific disorder.
16
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Discussions
Hyposexuality seems to be a hallmark of schizophrenics even in treatment naïve patients, being
more obvious after treatment, in chronicity. The issue of sexuality in bipolar women is rather
difficult to assess and compare partly to the heterogeneity of the disorder.
Conclusions
Sexual disorders are a special and frequent issue in schizophrenia and bipolar women,
displaying a wide range from low frequency, interest, dissatisfaction or even pain and a temporary
phase limited exacerbation of sexuality during manic episodes.
Keywords: sexual disorders, schizophrenia, bipolar, women
Introduction
Sexual disorders (SD) refer to a broad umbrella for various disorders, regarding sexual response
cycle e.g., desire, arousal, erectile response, orgasm, ejaculation, genital and pelvic pain, which
occur in more than 75% of sexual experiences, are enduring (more than three months), and produce
distress and low quality of life (1). Sexual functioning involves more than the above mentioned
physiological sexual phases but also the relational engagement, marital satisfaction. Sexual
disorders might be recorded in 30-80% (2) of schizophrenia patients, the majority being attributed
to treatment (3). The situation of bipolar patients in this regard is more complicated, appreciating
that almost one third complain of various sexual drive problems (4), raising up to 80% in inpatients
(5). It is usually ascertained that various drugs such as antipsychotics, antidepressants, mood
stabilizers could trigger or aggravate SD, being the major source of noncompliance, especially in
young and sexually active patients, with recent data of teratogenic effects of valproat acid (6, 7, 8).
These SD could be a hallmark of schizophrenia even before any treatment approach has been
initiated, partly due to autism, negative symptoms, isolation, affective blunting, and abstract
thinking problems (9). These SD are prominent during relapses but also in remission (10). Among
antipsychotics, prolactin raising ones (Olanzapine, Risperidone, Haloperidol, Clozapine) might be
responsible of 40-60 % of SD but also those prolactin sparing could produce 16-27% of SD (3).
Even though, the switch from first generation to second generation antipsychotics improved
sexual functioning, still medication is seen as a major barrier against plenary expression of
sexuality (3). The studies regarding SD are sparse due to hesitancy, reluctance, in spite the
disponibility of subjects and their interest to improve quality of life, and self-fulfilment.
Two separate cross-sectional studies, with similar design, aimed to investigate the presence of
sexual disorders in chronic schizophrenic and bipolar (depressive and manic) inpatient female
patients and to relate these to severity of the disease, misbelieves. The design, partial results were
previously published (11, 12, 13, 14). The first study compared 50 female chronic schizophrenic
inpatients, to matched controls and were explored by the following psychopatometric tools:
PANSS, GAF-severity of the disease, treatment emergent sexual side effects (UKU Side-Effects
Rating Scale), WHO-QOL Bref-quality of life, Sexual Dysfunctional Beliefs Questionnaire SDBQ.
The second study, a broader PhD thesis (14), assessed severity of depression (BDI), mania
(YMRS), frequency of sexual intercourse, fantasies, desire, lubrication, orgasm, dyspareunia
(Sexual Dysfunction index-SDI, the Index of Female sexual Function-FSFI), SDBQ in 81
17
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depressed, 31 manic and 61 matched controls. The inclusion criteria imposed the fulfilment of the
diagnostic criteria according to ICD-10, the absence of organic disease that might induce sexual
disorders (e.g., diabetes, neurological, endocrinological, urological, gynaecological, systemic
diseases), comorbidities (alcohol, psycho-active substances misuse, dependence), contraceptive
medication (14). All patients, admitted to the Second Psychiatric Clinic Cluj-Napoca, signed an
informed consent and the evaluations were in accordance to the Helsinki requirements, receiving
the approval of the local Ethics committee. A snap-shot of some of the results will be presented.
Results
There was stated from the very beginning that the focus was on chronic patients, e.g., at least
three prior episodes had to be recorded since the disorder elapsed. The two samples were different
not only from the diagnostic, therapeutical approach but also from the studied age, supposing the
potential sexually active period: 18-55 years in the schizophrenia sample, respectively 10-62 years
in bipolar patients (11,14). Among the demographical data, the two studies revealed similar age
means e.g. 35,45 (SD=6,85) schizophrenia, versus depressed 40,19 (SD=11,4), and manic 42,19
(SD=11,4), ANOVA of the latter group (F=2,67, p>0.05) being nonsignificant (11, 14). More
interesting seems the onset age, the duration of the disease (over 8 years), exposure to treatment
over 8 years (Table 1); a gap of over one year since the diagnosis and the treatment could be
recorded in schizophrenia, depressed patients, while manic patients beneficiated sooner of therapy.
There were used FGAs, SGAs, anticholinergics, anxiolytics, various types of antidepressants,
mood stabilizers.
Table 1. Demographic data of the samples

Diagnosis schizophrenia controls depressive manic controls
N 50 50 81 31 61
Age 35,45 (6,85) 35,48 (8,24) 40,39 (8, 9) 42,19 (11, 4) 37,62 (9,66)
(mean, SD)
Onset age 26 (7,67) 28 29
Duration dg 10,32 (6,55) 9.3 8,1
Duration tr 9,31(6,06) 8 8,1
Similar level of education was recorded in all patients but the employment status was generally
below the educational level, with a special mention of the tremendous early and extended level of
sick leave (64%) in the schizophrenia group (11). The marital status rendered evidence another
situation that might be put in relation with the disease but also with sexual functioning: in spite the
fact that the majority of patients were married or were engaged in a relationship, only half of the
schizophrenia sample could keep their relation (11). Similar situation was noted in the bipolar
sample, demonstrating a homogenous group sampling (F=2.67, p>.05) and education (F=5.25,
p>.05) (12, 14). 64% of schizophrenia inpatient women were sexually active (11). 54.4% (N=17)
of manic, 43.3% (N=31) of depressive female inpatients were sexually active, being significantly
inferior to controls 86.9% (N=53), chi-square-28.35, p<.001 (13, 14). FSFI detected among the
bipolar subjects, 75% sexual dysfunction, irrespective to depressive or manic pole (13, 14) (Table
2).
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Table 2. The prevalence of sexual dysfunctions in sexually active bipolar patients according cu FSFI
diagnosis sexual dysfunction without sexual dysfunction Statically mean
N, % N, %
depressive 27 (77,1) 8 (22,9) 2 0.262
p>0,05
manic 12 (70,6) 5 (29,4)
As with regard of the frequency of sexual intercourse, schizophrenic females reported in

majority 78% less than one intercourse/month, out of these 36% having no intercourse (p<0.001)
(11). Even though, 28% of schizophrenic patients were satisfied with their sexual life, in
comparison to controls, with clinical statistical meaning (11). The bipolar sample reported 4,23
(SD=5,32) coitus/month in depressive women, and 4,24 in manic (SD=2,72) at t=0.005, p>0.05,
but doubled as ideal frequency in manic patients (9.18, at t=2.89, p<0.05 (14).
An important issue is the level of psychopathology and sexual functioning. This has been
investigated by PANSS scores and GAF scores in schizophrenia. Briefly, there could be noticed
that the schizophrenia patients were moderate to severe ill, but stable during the admittance and
evaluation. PANSS scores did not correlate with the frequency of sexual intercourse, with false
beliefs about sexuality but positive correlate to the florid component of the positive subscale and
number of partners (11). But more important, sexual satisfaction could be guaranteed by adequate
adjustment, obvious by the GAF scale, and WHO-Qol Bref (11).
The psychopathology in bipolar sample, assessed by BDI in depressed patients and YMRS in
manic patients did not show any significant correlation weather active/inactive sexually (14).
Table 3. Comparison between depressive and manic patients regarding the change
of sexual interest due to the disease (14)
Group 2 P
depressive manic
N 14 0
yes
% 40.0% 0.0%
disease 9.35 <.001
N 21 17
no
% 60.0% 100.0%
This result shows the fact that depressive patients observed a reduction of their sexual interest
attributable to illness. The query on SDI, FSFI indicated modest levels of desire, excitation,
lubrication, sexual satisfaction in depressed patients (14). Depressive patients complained about
pain during penetration (14). The major differences of SD within the bipolar group are outlined by
Fig. 1.
Fig. 1. Patterns of sexual disorders in depression/mania (14)

depression mania
less sexual interest intense sexual fantasies
rare sexual intercourse high sexual arousal
discomfort good lubrication
pain sexual satisfaction
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The SDBQ has been validated on Romanian population (14). A ranking of the total scores of
this scale in the psychiatric population emphasized higher scores than controls in all groups with
comparable scores in schizophrenia and manic patients (Table 4). The merit of this tool is the
highlight of misbelieves regarding sexuality. Schizophrenia patients showed total higher scores,
more conservatism, sinful perception of sexuality and low body self-esteem (11). Within the
domains of the scale, depressive and manic patients scored higher on all in comparison to controls
(Table 4).
Table 4. Analysis of the mean, SD, total scores of the SDBQ items in schizophrenia, depressive, manic, controls
(11, 13, 14)
Items SDBQ schizophrenia controls depressive manic controls
Sexual conserve 30,96(5,31) 19,9(7,97) 25,96(8) 31,44(6.98 22,18(4,33)
Sexual wish-sin 17,72(3,73) 11,68(4,59) 12,6(4,33) 18,16(5,78) 11,58(4,38)
Age rel. beliefs 16,6(3,14) 11,2(3,61) 13.3(3,48) 16.96(3,6) 11.95(2,74)
Body im. beliefs 11,04(2,84) 8.04(3,41) 8,15(2,75) 10,33 (3,5) 7,5(2,65)
Denial affection 22(3,51) 19,3(1,9) 19,23(3,35) 21,23(2,36) 18,01(2,54)
Motherhood 12,44(2.19) 9,42(2.4) 10,4(2,24) 11,36(2,34) 9,85(2,5)
primacy
Total 110,7(14,4) 79,54(20,48) 89,14 109,48 81,07
Discussions
Both samples of patients emphasized a special situation, that of hospitalized ones, isolated from
their potential partners, on active medication, explaining partially the extend of the sexual
impairments. If sexual interest and involvement of schizophrenia patients are modest even before
the onset of the disorder due to the personality traits, they become more obvious during disease
onset (15) but are extensive in chronicity and long duration of treatment, unhealthy life-style, social
drift, but also during remission. One major barrier is to dissociate disease driven SD from those
triggered by medication. Negative symptoms, especially hinder initiation and joy of sexual
relations, deterioration of intimate relations; frequent relapses, depression, and obesity might be as
well important in this regard Certain features seem to be typical for female schizophrenia patients:
the first sexual experiences, marriage, child bear might have occurred before disease onset and
even when such SD are present, they are less obvious, accentuated during hospitalizations (1). To
the topic of sexuality in bipolar disorder: there is general agreement of hypersexuality, promiscuity,
disruptive couple relations during manic, hypomanic episodes, less sexual interest, satisfaction in
depression (16). The hallmark is this great variability across polarities. Hiposexuality in manic
bipolar I female patients has been observed by other authors as pain in depressive women (10).
Conclusions
SD investigated in schizophrenic, bipolar female inpatients were detected and ranged from
diminished sexual interest, involvement, low frequency of sexual intercourse, various dysfunctions
of the sexual response cycle, conservatorism, sinful perception of sexuality. There could be
established some patterns of sexuality in schizophrenia patients (anhedonic, with low sexual desire,
moderate arousal, rare complete coitus) (11) in depression (diminished sexual interests, rare
intercourse, dissatisfaction, dyspareunia) (14) and in mania (intense sexual fantasies, high arousal,
good lubrication, sexual satisfaction) (14). These SD were modest associated with severity of
psychopathology, improving with better adjustment (11, 12, 13, 14).
20
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REFERENCES
1. McMillan, E., Sanchez, A., Bhaduri, A., Pehlivan, N., Monson, K., Badcock, P., Thompson, K., Killackey,
E., Chanen, A., O’Donoghue, B. (2017). Sexual functioning and experiences in young people affected by
mental health disorders. Psychiatry Research, 253, pp. 249-255.
2. Baggaley (2008). Sexual dysfunction in schizophrenia: focus on recent evidence. Hum Psychopharmacol Clin
Exp doi: 10.102/hup.924
3. Souaiby, L., Kazour, F., Zoghbi, M., Bou Khalil, R., Richa, S. (2019). Sexual dysfunction in patients with
schizophrenia and schizoaffective disorder and its association with adherence to antipsychotic medication. J
of Mental Health. doi.org/10.1080/09638237.2019.1581333
4. Downey JI. (2011). Driven sexual behavior in bipolar spectrum patients: psychodynamic issues. J Am Acad
Psychoanal Dyn Psychiatry, 39, pp. 77-92.
5. Marzani-Nissen, G., Clayton, A. (2004). Sexual disturbances and depression, WPA Bulletin on Depression,
9 (28), pp. 1-5.
6. Smith, S. (2007). Drugs that cause sexual dysfunction, Psychiatry, 6, 3, pp. 111-114.
7. Ketter, T.A. (2010). Handbook of Diagnosis and Treatment of Bipolar Disorder, American Psychiatric
Publishing, Inc., Washington DC.
8. Marzani-Nissen, G., Clayton, A. (2004). Sexual disturbances and depression, WPA Bulletin on Depression.
9, 28, pp. 1-5.
9. Marques, T.R., Smith, S., Bonaccorso, S., Gaughran, F., Kolliakou, A., Dazzan, P., Mondelli, V., Taylor, H.,
Diforti, M., McGuire, P.K., Murray, R.M., Howes, O.D. (2012). Sexual dysfunction in people with prodromal
or first-episode psychosis. Br. J. Psychiatry 201, pp. 131-136.
10. Elkhiat, YI, Fathy Abo Seif, A., Khalil, M.A., Fayek Gamal El Din, S., Saad Hassan, N. (2018). Sexual
Functions in Male and Female Patients with Bipolar Disorder during Remission. J Sex Med,
/doi.org/10.1016/j.jsxm.2018.06.002
11. Micluţia, I. V., Popescu, C. A., Macrea, R. S. (2008). Sexual dysfunctions of chronic
schizophrenic female patients. Sexual and Relationship Therapy. 3, (2), pp. 119-129.
12. Damian, L., Micluția I. (2013). Bipolar female inpatients and their sexuality. Rom J Psychofarma. 13(3), pp.
129-135.
13. Damian, L., Micluția I. (2015). Results from the study regarding sexual disorders of female bipolar patients.
Rom J Psychopharma. 15(1), pp. 31-35.
14. Damian, L. (2016). Aspecte ale sexualităţii femeilor cu tulburare afectivă bipolară. Ed. Medicală Universitară
Iuliu Haţieganu, Cluj-Napoca.
15. van Bruggen, M., van Amelsvoort, T., Wouters, L., Dingemans, P., de Haan, L., Linszen, D. (2009). Sexual
dysfunction and hormonal changes in first episode psychosis patients on olanzapine or risperidone.
Psychoneuroendocrinology (2009) 34, pp. 989-995.
16. Kopeykina, I., Kim, H-J., Khatun,T., Boland,J., Haeri, S., Cohen, L., Galynker, I. (2016). Hypersexuality
and couple relationships in bipolar disorder: A review. Journal of Affective Disorders, 195, pp. 1-14.
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The Importance of the Supportive Psychotherapy for the Cancer

Patients and their Families
NEAGA Susanu1
1PhD, Lecturer, “Danubius” University, Galati (ROMANIA)
Email: neli_susanu@yahoo.com
Abstract
Psychotherapy should be included in the treatment of the patients, especially those diagnosed
with cancer. Psychological/psychotherapeutic intervention significantly reduces the risk of major
psychiatric disorders and helps the patient to improve his/her mental condition through better
emotional control and adaptation to illness and treatment. The study, conducted over a two-month
period, involved 40 patients diagnosed with cancer. It is known that self-esteem and self-
acceptance decrease very much in finding the diagnosis, in many cases depressive disorder occurs.
The role of the family is important in supporting the cancer patient and even the participation of
the family members along with the patient in the support groups. This comparative study has shown
that participation of cancer patients in psychotherapeutic support groups has a positive effect in the
fight against psychiatric disorders.
Keywords: cancer, self-esteem, supportive psychotherapy, family
Psychotherapy is an interdisciplinary field, located at the border between medicine and

psychology [1]. It is a comprehensive, deliberate and planned treatment, through scientific means
and methodologies, with a clinical and theoretical framework centred on reducing or eliminating
symptoms, mental disorders or psychosocial and/or psychosomatic suffering conditions as well as
dysfunctional behaviours. (Definition given to psychotherapy by FRP – Romanian Federation of
Psychotherapy) [2].
Psychotherapy in the world is practiced by psychologists, physicians, psychiatrists, social
workers, theologians, counsellors or graduates of other higher education and who have
psychotherapy training. In Romania, psychotherapists are psychologists, doctors, psycho-
educationalist and social workers with training in a particular school or a method of psychotherapy)
[3].
The desire to find a saving solution can determine the patient to accept also alternative therapies
in treating the disease. They find support, mainly, in family members, friends, colleagues. In some
cases, requiring specialized help may become a necessity; aid may be given especially as a special
therapy called supportive therapy. The purpose of this form of psychotherapy is to help sick people
(especially those with serious diagnoses), to accept, understand and manage the difficult situations
they face.
During the psychotherapy sessions with the patients diagnosed with cancer, there are also used
techniques that belong to the behavioural and cognitive psychotherapeutic school [4]:
➢ Behavioural psychotherapy: – starts from the premise that any normal or abnormal
behaviour is the product of what the individual learned or did not learn. Psychiatric illnesses
22
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are learned skills or involuntary acquired responses, repeated and reinforced to specific
environmental stimuli. Purpose: – learning behavioural alternatives to be practiced both in
the therapeutic environment and beyond.
➢ Cognitive psychotherapy: – it starts from the premise that psychological disturbances are
due to judgmental errors on the situations faced by the individual. The cognitive approach
is structured on the analysis of reality, which causes the patient to conscientiously verify
his/her thinking and correctly assess the consequences of the situations he/she is
experiencing.
Communication of the Diagnosis
Diagnosis “cancer” is always difficult and hard to accept by the most powerful people. The
moment of finding such a diagnosis is often a shock. It is extremely important to communicate the
diagnosis, which can be considered the first step towards the patient’s subsequent development.
Psychologists and doctors are of the opinion that cancer diagnosis should be said when the
patient is ready to receive it. This communication also involves training the physician, who must
communicate the truth, about his illness. Communication is a process, it does not end after the
diagnosis is told, and the patient must be supported and encouraged by the doctor and his/her family
[5].
It is preferable to work in mixed teams: doctors and psychologists. The role of the psychologist
is extremely important; he must prepare the patient and choose the right time for further
information on his illness [6, 7].
The Psychological Stages of the Cancer Patient
Studies on the perspective for the disease progression have shown that there are more stages of
evolution since the patient finds he has an incurable disease. Thus, five stages were noted:
• Shock and denial of diagnosis;
• The question “why me”?
• negotiating with the doctors with the Divinity, in order to gain time;
• depression (with suicide risk);
• accepting disease and prognosis as inevitable;
These stages do not take place in all cases, but their knowledge by the psychologist and the
patient's family helps them to help them according to their psycho-behavioural states. By studies
of contemporary psychoanalysis, it has been found that cancer patients develop during their illness
their own defence mechanisms [8]. These are automatic psychological processes that protect the
individual against the anxiety of internal and external stressors.
The Role of Emotional Support of the Specialists Offered to the Patient and His/Her Family
The therapeutic team has an essential role. The patient benefits from specialized treatment
without exculpating family support that is of real benefit to the healing process. Thus, the
psychologist makes initial assessment of personality and periodic re-evaluations of mood and
patient adaptation. The psychiatrist intervenes when a depressed mood occurs. Oncologists,
radiotherapists, surgeons who are invested by patients with sometimes magical authority, and
therefore the messages they transmit (verbal and nonverbal) have a very strong resonance inside
23
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the patient [9, 10, 11, 12]. The family has a very important role to play in supporting the patient if
they also receive specialist help, so they will be counselled psychologically. Supporting people
experiencing the diagnosis and effectively the cancer disease means to take care of them at a time
when their illness has substantially altered their lives. These patients are very receptive to
psychotherapeutic treatment.
Another form of therapy, group therapy (a particular group of women with breast cancer), works
effectively, each person benefits from confrontations with the emotional experience caused by the
disease. Affiliation to a group favours overcoming crucial moments, fostering reflection, sharing
feelings and mutual support [13].
Comparative Study on the Effects of Supportive Psychotherapy on Patients Diagnosed with

Cancer
The objective of the research is the analysis of the way of structuring of some personality
factors, compared to the patients participating in psychotherapy and the patients who did not benefit
from psychotherapeutic support.
The research hypothesis: We assume that the self-esteem of the patients participating in the
psychotherapeutic support group has higher values than the patients who did not participate in the
supportive psychotherapeutic group.
The research goal was to know the significant personality factors, their way of structuring
predisposing to increased self-esteem, a positive emotional state, and the use of results for
subsequent activities in psychotherapy groups.
The sample of the research was made up of:
- group A 20 persons diagnosed with different types of cancer, women and men aged 35 to
65 who accepted to participate in psychotherapy sessions;
- group B (control), 20 persons diagnosed with different types of cancer, women and men
aged 35 to 65 who did not participate in any form of psychological counselling or
psychotherapy and have never discussed with a psychologist/psychotherapist.
In setting up the sample, we considered each patient to be part of a complete family (husband,
wife, children, and grandchildren).
The tools used were the following:
1. Self-esteem – the Rosenberg Scale. The Self-esteem Scale Questionnaire was developed in
1965 by the American Sociologist (Jewish origin) Morris Rosenberg (Self-Esteem Scale –
RSES) and published in the same year in “Society and the Adolescent Self-image”
Princeton, NJ: Princeton University Press. RSES has a good internal consistency, the
Cronbach alpha coefficient being 0.89 (near excellent = 0.90), and fidelity test-retest is
between 0.85 and 0.88 (Rosenberg, 1965).
2. Self-Acceptance Scale, developed by Emanuel M. Berger, a renowned psychologist, the
self-acceptance scale is a measure of self-consciousness, an image of how you can see
yourself in the report with reality. You can have a distorted picture of yourself, dominating
either overestimation or underestimation.
Research Results
As can be seen in the following graphs, there are significant differences between group A
subjects participating in this study compared to group B who did not participate in any form of
24
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psychological counselling or psychotherapy. The results of supportive psychotherapy have greatly

improved patients’ mental health and, to a significant extent, have also been influenced by the
results of the medical tests. Trust, hope, courage are examples of qualities that the patients have
acquired during their participation in the psychotherapeutic support group.
Conclusions
The goal of supportive psychotherapy is to help cancer patients overcome and get well through
the diagnosis and the treatment period. We found that there are also differences in the degree of
involvement of patients’ family members who, even if they did not participate in the support group,
encouraged the patient to participate and seek specialist help. This study shows that there is a
significant percentage between the group participating in the psychotherapy and the control group.
We can conclude that the hypothesis has been confirmed.
Group A. Self-esteem, graphic representation

40
30
20 subiect
scor
10
0
1 3 5 7 9 11 13 15 17 19
Group B. Self-esteem, graphic representation

30
25
20
15 subiect
10 scor
5
0
1 3 5 7 9 11 13 15 17 19
25
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Group A. Self-acceptance scale, graphic representation

200
150
100 Serie1
Serie2
50
0
1 3 5 7 9 11 13 15 17 19
Group B. Self-acceptance scale, graphic representation

140
120
100
80
subiect
60
scor
40
20
0
1 3 5 7 9 11 13 15 17 19
The Effects of the Supportive Therapy
The main benefits of participating in the oncology-supportive psychotherapy or support groups

are the following:
- Increasing self-esteem.
- Increasing the level of self-acceptance of patients (after some interventions).
- Accepting to participate in a support group.
- Meet other people who are facing the same problem
- Changing cognition over health
- Exit isolation and solitude.
- Identification with people with the same disease and who accepted the diagnosis.
- Opportunity to express emotions, thoughts, fears.
- Information on methods, treatment steps and alternative therapies.
- reinvigorating the self-esteem of assertiveness and autonomy.
- Diminishing depression and emotional fragility.
- Increasing the energy needed to cope with the changes caused by the disease.
- Increasing the capacity to face a poor physical condition.
- Increasing confidence in the ability to accept the disease
- Ability to rebuild a new and integrated image of the self.
- Reducing dependence on family, health, society.
26
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Support Group – Help for the Cancer Patients
Awareness of the fact that they can contribute to their own path of care, healing, and gaining a
better existential significance determines the members of the patient's family and of them to
participate in the psychotherapeutic support groups. Psycho-oncology patients are advised to opt
for individual, group, family psychotherapy, favouring a recapitulation of their own lives and
setting priorities for the future.
Within the support group, patients have a sense of sharing experiences and mutual support that
can be maintained after formal treatment, through regular social discussions and meetings. This
perception can be extremely important, since it has been shown that social isolation is as strong as
smoking or high cholesterol in increasing the rate of morbidity.
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Self-perception and Eating Behaviour in Obesity and Diabetes
MOROȘANU Andreea1,2, MOROȘANU Magdalena2, CLINCIU Aurel Ion3

1 “Dunarea de Jos” University of Galati (ROMANIA)
2 Diamed Obesity SRL, Galati (ROMANIA)
3 Transylvania University of Brașov, Faculty of Psychology and Education Sciences (ROMANIA)
Emails: andreeamorosanu17@gmail.com, magda_m28@yahoo.com
Abstract
Self-perception (SP), self-esteem (SE) and eating behaviour influence therapy and quality of
life of persons with obesity and/or diabetes. Our study investigated 105 persons with obesity or
diabetes mellitus (DM) who completed questionnaires regarding self-perception (SP), body self-
perception (BSP), eating disturbances (ED), self-esteem (SE) and were measured for
anthropometric parameters and social data. The study detected variations in self-esteem, body self-
perception, self-perception, and eating disturbances in people with diabetes and obesity. Specific
differences have been noted between obesity and diabetes. The study concluded that SP, BSP and
social SE (SSE) were related to body mass index (BMI) and abdominal circumference (AC) in
obesity, while persons with diabetes had higher tendency toward ED and lower inner SE (ISE),
along with correlation between ED and BMI.
Keywords: Body image self-perception, body satisfaction, self-esteem, eating behaviour, obesity, diabetes
Introduction
Self-perception (SP), self-esteem (SE) and eating behaviour are areas of great interest in study
of obesity and diabetes, for their implications in evolution and therapy of these diseases [1, 2]. In
studies, body image self-perception varied with body mass index (BMI) in women with type 2
diabetes. [3] Low body satisfaction and increased BMI were directly related in girls. [4, 5] Body
dissatisfaction was related to low self-esteem and depression, while perceived overweight was
linked to low self-esteem in women. [6] Eating disorders are frequently associated and generate
overweight and obesity. Disturbed body image was related to abnormal eating behaviours or
attitudes and could precede dysfunctional eating behaviours. Decreased body satisfaction was
associated with increased inadequate behaviours like unhealthy diets and compulsive eating. Body
image improvement mediated the effects of obesity treatment and self-adjustment of food intake
after 12 months. [7] Our study investigated the relations between SP, body self-perception (BSP),
eating disturbances (ED), social self-esteem (SSE), inner self-esteem (ISE) and weight status in
and between obesity and diabetes mellitus (DM).
Methods and Study Group
The study included 105 adult persons with obesity or diabetes mellitus from one diabetes and
metabolic disease center in Galati, Romania, among which 60 women (57,14%), 45 men (42,86%),
mean age 52,23±14,04 years (minimum-20 years, maximum-80 years), 41 persons with obesity
28
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and 64 persons with diabetes (type 1 and type 2). We collected anthropometric data: weight, height,
BMI, abdominal circumference (AC). Study subjects self-completed five questionnaires:
Questionnaire for Evaluation of Eating Disturbances Clinciu (QEED Clinciu) with 71 items and
three factors: self-deception, anorexic propensity and bulimic propensity; Questionnaire of Self
Perception Clinciu (SP Clinciu) with 30 items and four factors: self-value, success, criticism and
total (self-esteem), Existential Themes Clinciu with 20 items (included in SP Clinciu, but separate
parameter); Questionnaire of Body Self Perception Clinciu (BSP Clinciu) with 48 items and seven
factors: height, weight, head, torso, limbs, particular aspects [8,9]; Rosenberg Self Esteem
Questionnaire (RSE) for ISE with 10 items [10]; and Social Self-Esteem Inventory (SSEI) for SSE
with 30 items [11, 12]. All questionnaires were validated, first three in Romania on general
population and the last two on international general population and had good internal consistency
scores (> 0.7) The data were collected and analysed by SPSS 17.0. Statistical significance was
reached for p<0.05.
Results and Discussions
For the subgroups analysed, the mean age values were significantly different, with younger
people in the obese subgroup. The weight, BMI and AC were not significantly different between
subgroups. These results may be due to the increased prevalence of obesity in diabetes, which
makes the subgroups comparable. (Table 1)
Table 1. Age, weight, BMI and AC on subgroups with obesity and diabetes
Obesity Diabetes Test T
Mean ± standard deviation Mean ± standard deviation
Age 45,00±13,74 56,86±12,24 p=0,000011
Weight (kg) 92,53±13,95 93,31±22,18 p=0,826
BMI (kg/m2) 32,43±4,92 33,22±7,77 p=0,084
AC (cm) 103,77±13,29 110,22±21,29 p=0,563
The distribution of age values was asymmetric to the left with bimodal appearance, in the case
of obesity, and asymmetric to the right with a tendency to normal appearance in the case of diabetes.
Body weight and BMI values were asymmetrically distributed to the left (the “I” curve) per
subgroup. The distribution curve of the AC had a normal distribution tendency, slightly shifted to
the left for both subgroups with extreme interstices in the central area for the obese subgroup.
Analysis of parameters total BSP, total QEED, QEED deception, QEED anorexia, QEED
bulimia, SP self-esteem (total), ET, ISE and SSE by single-sample t-test showed statistically
significant values, with the exception of SP total (self-esteem) that was nonsignificant. (Table 2.)
Table 2. Average scores for psychological parameters

Parameter Number Mean Standard deviation
BSP height-weight-gender 81 2,20 2,561

BSP head 81 24,28 17,342
BSP torso 81 3,77 11,893
BSP limbs 81 14,79 14,385
BSP particular aspects 81 7,62 10,749
BSP total 84 51,90 49,142
QEED deception 105 8,70 6,792
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QEED anorexia 105 8,29 5,205

QEED bulimia 98 3,66 3,581
QEED total 99 19,76 12,951
SP self-value 84 15,51 10,209
SP success 84 9,56 10,714
SP criticism 84 6,83 11,440
SP total (self-esteem) 84 31,90 29,055
ET 85 20,58 16,084
ISE 84 28,05 4,802
SSE 84 115,44 31,519
Total and subscales BSP, total and subscales QEED had abnormal distributions of values.
Distribution of total and subscales SP and ET values indicated: abnormal distribution of SP self-
value; curve with normal shape, deviated to the right for SP success, SP criticism; curve slightly
diverted to the right for SP total (self-esteem); bimodal curve for ET.
Psychological parameters in relation with weight status

Total BSP was inversely correlated with BMI and AC, while the total QEED score was directly
correlated with BMI and AC for the entire study group. ISE score was inversely correlated with
AC. (Table 3) The higher were the BMI and AC, the lower was BSP, and the higher tendency to
eating disorders was reported. The results are consistent with the literature that indicates the
association of obesity and diabetes with the alteration of self-perception and body image through
body dissatisfaction and eating disorders. A particular, original aspect is the link between specific
body perception and weight status, even if the correlation is of low intensity.
Table 3. Relationship between psychological parameters and BMI, AC for the whole group
Correlations BMI AC
(Pearson coefficient, r) r p N r p N
BSP total - 0,364 0,001 84 - 0,295 0,015 68
QEED total 0,314 0,002 99 0,271 0,013 83
SP total - 0,162 0,141 84 - 0,113 0,359 68
ET - 0,207 0,057 85 - 0,188 0,121 69
ISE - 0,154 0,161 84 - 0,291 0,016 68
SSE - 0,201 0,055 84 - 0,217 0,076 68
N = number of Subject
BSP and ET scores were inversely correlated with BMI and AC, while SP and SSE scores were
inversely correlated only with BMI for the obesity subgroup. (Table 4) The result confirms earlier
research on impairment of self-perception and self-esteem with weight gain, the correlation
intensity being average in obesity and low in diabetes. QEED score was directly correlated (low
intensity) with BMI and AC, and the ISE score was inversely correlated with AC in people with
diabetes. (Table 5) It was surprising that the link between food disturbances and weight
abnormalities occurred only in diabetes, possibly due to stress caused by chronic illness, dietary
restrictions or other mechanisms, such as lowering self-esteem.
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Table 4. Relationship between psychological parameters and BMI, AC in obesity

Correlations BMI AC
BSP total - 0,511 0,002 34 - 0,475 0,006 32
QEED total 0,245 0,155 35 0,052 0,776 33
SP total - 0,446 0,008 34 - 0,106 0,565 32
ET - 0,507 0,002 35 - 0,442 0,010 33
ISE - 0,219 0,214 34 - 0,241 0,183 32
SSE - 0,464 0,006 34 - 0,316 0,078 32
Table 5. Relationship between psychological parameters and BMI, AC in diabetes

Correlations BMI AC
BSP total - 0,271 0,057 50 - 0,183 0,286 36
QEED total 0,326 0,009 64 0,307 0,030 50
SP total - 0,025 0,865 50 - 0,101 0,556 36
ET - 0,013 0,929 50 0,010 0,954 36
ISE - 0,114 0,432 50 - 0,340 0,043 36
SSE - 0,061 0,676 50 - 0,182 0,287 36
In order to analyse the differences between obesity and diabetes for psychological parameters
on total and on subscales, we used the t test for independent samples. (Table 6, Table 7) Values
of SP self-value, SP success and SP total (self-esteem) were significantly lower for people with
diabetes than for those with obesity. People with diabetes recorded higher values of total QEED
and lower values of SP criticism, at the limit of statistical significance. (Table 6, Table 7) Self-
perception was lower in people with diabetes, showing diminished self-esteem, which could be due
to chronic disabling disease (diabetes), self-monitoring and self-management which required
permanent attention for and conscience of the disease, more than in obesity. Although the other
differences were insignificant, people with diabetes may be more prone to eating disorders, with
the test being almost significant. The correlation of QEED-BMI in people with diabetes can support
this assumption.
Table 6. Psychological parameters in obesity and diabetes

Parameter Obesity Diabetes
N Mean Standard N Mean Standard
deviation deviation
BSP height-weight-gender 33 2,64 2,074 48 1,90 2,830
BSP head 33 25,24 18,038 48 23,62 17,008
BSP torso 33 5,12 12,749 48 2,83 11,309
BSP limbs 33 16,09 15,466 48 13,90 13,687
BSP particular aspects 33 8,94 12,168 48 6,71 9,684
BSP total 34 55,74 57,366 50 49,30 43,095
QEED deception 41 7,66 7,151 64 9,38 6,521
QEED anorexia 41 8,29 5,879 64 8,28 4,773
QEED bulimia 34 3,18 3,362 64 3,92 3,692
QEED total 35 16,43 12,458 64 21,58 12,948
SP self-value 34 20,41 8,617 50 12,18 9,928
SP success 34 14,00 10,109 50 6,54 10,130
SP criticism 34 9,62 12,203 50 4,94 10,599
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SP total (self-esteem) 34 44,03 28,415 50 23,66 26,736

ET 35 23,26 17,571 50 18,70 14,851
ISE 34 27,76 4,961 50 28,24 4,732
SSE 34 114,59 31,969 50 116,02 31,523
Table 7. Differences of psychological parameters between obesity and diabetes

Parameter Differences obesity-diabetes (t test)
t df p
BSP height-weight-gender 1,284 79 0,203
BSP head 0,410 79 0,683
BSP torso 0,849 79 0,398
BSP limbs 0,673 79 0,503
BSP particular aspects 0,879 58,399 0,383
BSP total 0,556 57,486 0,580
QEED deception - 1,267 103 0,208
QEED anorexia 0,010 72,679 0,992
QEED bulimia - 0,981 96 0,329
QEED total - 1,917 97 0,058
SP self-value 3,930 82 0,0002
SP success 3,316 82 0,001
SP criticism 1,867 82 0,065
SP total (self-esteem) 3,341 82 0,001
ET 1,291 83 0,200
ISE - 0,443 82 0,659
SSE - 0,203 82 0,840
Assessment of internal consistency and fidelity for the questionnaires used

Internal consistency, homogeneity and fidelity for the tested scales were good, very good or
excellent. The values are presented in Table 8.
Table 8. Assessment of internal consistency and fidelity for questionnaires on study group
Alpha Variance Spearman Brown coefficient
Cronbach Items order Even-Odd
BSP total 0,976 2454,378 0,907 0,985
QEED total 0,944 199,737 0,903 0,959
QEED deception 0,905 46,133 0,903 0,903
QEED anorexia 0,869 27,091 0,808 0,871
QEED bulimia 0,859 12,824 0,837 0,902
SP total 0,959 952,433 0,838 0,973
ET 0,911 277,021 0,762 0,950
ISE 0,742 22,794 0,753 0,881
SSE 0,904 931,063 0,857 0,930
Study limits. Some questionnaires were incomplete, losing their data quality. The sample
included a sufficient but still reduced number of subjects. A larger group of people could generate
more accurate results than those obtained in the present study, including those at the limit of
statistical significance. Another limit of research was the lack of a control group (people without
diabetes or obesity) that would have enriched the data obtaining the magnitude of the parameters’
difference from general population. This path can be addressed in future research.
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Conclusion
The importance of the study lies in highlighting variations in self-esteem, body self-perception,
self-perception, and eating disturbances in people with diabetes and obesity. Specific differences
have been noted between obesity and diabetes. SP, BSP and SSE were related to BMI and AC in
obesity, while persons with diabetes had higher tendency toward ED and lower ISE, along with
correlation between ED and BMI. Research can be the starting point of more complex studies in
the field of self-esteem, body image and eating behaviour in people with diabetes and obesity and
may have implications in therapeutic interventions for management of nutrition disorders with the
purpose of reducing obesity and diabetes.
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From Depression to Human Immunodeficiency Virus – A Case

Report
SAPIRA Violeta1, LUNGU Mihaiela1, TELEHUZ Anca2

1Emergency Clinical County Hospital “Sfantul Apostol Andrei” Galati, “Dunărea de Jos” University of Galati, (ROMANIA)
2Slobozia Emergency County Hospital, (ROMANIA)
Email: violetasapira@yahoo.com
Abstract
Introduction
Human immunodeficiency virus (HIV) infection is often preceded or accompanied by
neuropsychiatric symptoms, including depression. This fact was evaluated in most of the clinical
studies to date as associated with HIV infection already diagnosed.
Case report
We report a case of a 46-year-old woman patient with no prior diagnosed pathology, suffering
from depressive disorder for roughly 6 months, with a progressive evolution under treatment.
Blood tests showed a moderate normochromic normocytic anaemic syndrome of unspecified
origin. Given the fact that depressive syndrome has not improved under treatment, a cerebral
computed tomography (CT) scan and a cerebral magnetic resonance imaging (MRI) are decided,
revealing an expansive cerebral process which in turn recommends performing stereotactic biopsy,
but the family of the patient refuses the procedure. The patient is neurologically evaluated and after
considering the cerebral MRI pattern and the presence of anaemia, an HIV and syphilis detection
test is decided, revealing a positive result for HIV infection. An antiretroviral therapy is instated,
resulting in clinical and imagistic favourable evolution.
Conclusions
Each patient and each case are individual and is to be approached as such. Depression in a
progressive evolution under treatment requires imagistic evaluation (cerebral CT scan, ideally
cerebral MRI).
Keywords: Human immunodeficiency virus (HIV) infection, depression, expansive cerebral process, magnetic resonance imaging
Introduction
The major depression is the most frequent psychiatric manifestation associated with human
immunodeficiency infection (HIV) [1, 2, 3] and it has a big influence over the quality of life on
this patient. Even if a precocious diagnosis and the initiation of an antiviral therapy has led to a
decrease in deaths caused by acquired immunodeficiency syndrome (AIDS), it is estimated that in
2030, HIV infection will be the main cause for disability followed by major depression disorder
[4, 5].
And as the two conditions can coexist, the social impact will be even greater because the
depression in HIV-positive patients is a predictor of negative clinical outcomes [4, 6, 7].
34
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A review of the literature showed that only a few clinical studies assess depression as a risk
factor for HIV infection [4]. These studies demonstrate that people with major depression disorder
have an increased risk of infection, facilitating transmission of the human immunodeficiency virus
[8, 9]. Rosenberg et al., highlighted a prevalence of the HIV infection eight times higher among
psychiatric patients compared to the general population [10].
Meade et al., confirmed high prevalence of HIV infection among the patients with severe
psychiatric disease [11]. Most of these patients had behavioural disorders associated with increased
transmission risk for HIV: unprotected sexual contact with multiple partners and administration of
intravenous drug with the syringe [4, 11]. Also, patients with severe depressive disorders have a
probability of five times higher to have unprotected intercourse, especially with a paid female
partner [12].
With regard to the association of depression with HIV infection, more research has evaluated
the incidence of major depression among HIV positive population. Even if depression is described
in all phases of infection with HIV [4], studies have shown a higher prevalence of major depressive
disorders in the advanced stages of the disease. The prevalence of the major depression disorders
among people with HIV infection varies form 7,2% to 71,9%, this being explained by the size of
the sample, different scales and evaluation questionnaires that have been used in the studies [13].
Case report
We present a 46-year-old woman’s case, with no prior medical history, that had been diagnosed
and treated for depression for 6 months, depression that apparently occurred in full health status.
The patient was admitted in the medical department with great fatigue and progressive
depression despite the treatment. Blood tests showed a normochromic normocytic anaemic
syndrome. A superior and inferior digestive endoscopy was performed without any results that
could explain the anaemic syndrome.
At this point it is worth mentioning from her anamnestic history that she was a divorced woman
that had sexual intercourse with two partners in the last five years.
Because the state of the patient is worsening and the depression syndrome is progressive a
cerebral computed tomography (CT) scan was performed and revealed a left fronto-parietal
expansive brain process. A cerebral magnetic resonance imaging (MRI) with gadolinium contrast
followed and showed a heavy solid mass in deep cerebrum area, in which gadolinium is captured
peripherally. That mass was located fronto-parietal with extension to left basal nuclei (Fig. 1). A
similar but smaller mass was discovered in left occipital area also.
The patient was transferred in the neurology department to continue the investigation due to
suspicions of cerebral metastases. A thoracic-abdominal-pelvic CT scan was performed with no
other neoplastic process found and all tumour markers were negative.
Without a clear etiologic diagnostic, the imagistic aspects and the presence of the anaemic
syndrome require a HIV and syphilis detection test revealing a positive result for HIV infection.
The viral load in the blood determination was 1019520 copies/ml, lymphocytes T-CD4 – 72
cell/mm3, cerebrospinal fluid analysis with protein concentration of 79 mg/dl, glucose
concentration of 44 mg/dl, elements number 1 cell/mm3, HIV-RNA 133922 copies/ml and fungal
culture was negative. The serology for toxoplasma Gondi (immunoglobulin G) was positive.
35
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Fig. 1. The appearance of the cerebral MRI of the cerebrum tumour processes
The therapy for human immunodeficiency and toxoplasmosis was initiated (the MRI imaging
was extremely suggestive and the serology for toxoplasmosis was positive), with favourable
evolution, improving overall state and depression and reducing the size of the intracerebral mass.
Discussion
An association between depression and chronic illnesses is common, but it is often

underdiagnosed and undertreated because symptoms like fatigue, insomnia, decreased appetite are
commonly found both in depression and in chronic diseases [14, 15, 16]. Additional there is a
perception that depressive symptoms are just the negative consequences of the diseases [14, 17].
Signs and symptoms of depression are similar in patients with HIV infection and in the ones
without infection [4]. The presence of apathy and anhedonia associated with diminished morning
mood is more commonly caused by depressive illness [4,17], while memory disorders and fatigue
are more likely to be independent of major depression disorder, being caused by HIV infection by
immune inflammatory neurogenic pathways [4, 19].
Different studies and reviews have found a bidirectional association between HIV infection and
depression, which implies a complex biological and psychosocial interaction [4, 13].
Recent studies have confirmed a correlation between depression, low level of CD4 and large
viral load in patients with HIV infection, announcing a faster progression to AIDS [4, 20] [21, 22].
36
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Patients with CD4 cells less than 200/mm3 had a 2,1 times higher risk of developing depression
than patients with values of CD4 greater 500/mm3 [14].
The particularity of the case lies in the fact that a persistent depressive syndrome under treatment
has led to the diagnosis of HIV infection, after imaging evaluation (cerebral MRI with contrast
substance) and determining serology for HIV. Depression can be explained by the presence of
cerebrum processes (cerebral toxoplasmosis) and may be secondary to the low number of T-CD4
lymphocytes (72 cell/mm3) and big viral load (1019520 copies/ml).
Managing depression among HIV-positive patients can lead to better prognosis: improves
quality of life and increases adherence to medication [23]. The selective serotonin re-uptake
inhibitors (SSRIs) are considered first-line medications for the treatment of depression in patients
with HIV infection [1], sertraline and escitalopram being the first therapeutic option [1, 24].
Treatment should be started with low doses and a slow titration to avoid complications
especially in patients with advanced disease, or those with complex therapeutic regimens [1].
Conclusions
Patients with progressive depressive symptoms under treatment should be imagistic evaluated
(cerebral CT or cerebral MRI).
Also, taking into account the increased incidence of HIV infection among psychiatric patients,
HIV determination should be a routine test, especially in younger patients.
Physicians of HIV infected patients should be able to assess signs of depression and require
psychiatric assessment whenever necessary. Identification and proper treatment of depression is an
integral part of the care of HIV-positive patients.
Informed consent
The patient’s informal approval has been obtained and recorded in the chart.
Author contributions
All the authors have equal contributions in this presentation.
Ethical approval
This article does not contain any studies with human participants performed by any of the authors.
Financial disclosure: none
Grand information
This article did not receive any specific grand from funding agencies in the public, commercial or
not-for-profit sectors.
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18. Dubè B, Benton T, Cruess DG, Evans DL (2005). Neuropsychiatric manifestations of HIV infection and
AIDS. J Psychiatry Neurosci.; 30(4): pp. 237-46.
19. Capuron L, Pagnosi G, Demetrashvili MF, Lawson DH, Fornwalt FB, Woolwine B, et al., (2007). Basal
ganglia hypermetabolism and symptoms of fatigue during interferon-alpha therapy.
Neuropsychopharmacology.; 32(11): pp. 2384-92.
20. Alciati A, Gallo L, Monforte AD, Brambilla F, Mellado C (2007). Major depression-related immunological
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54, p. 66.
24. Wolff CL, Ruben Alvarado M, Wolff R (2010). Depression in HIV infection: Prevalence, risk factors and
management. Rev. Chil. Infect.; 27: pp. 65-74.
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Psychiatric Disorders Associated with Endocrine Dysfunctions
CHIRITA Anca Livia1, POPESCU Mihaela1, CALBOREAN Veronica1,

GHEORMAN Victor1*, UDRISTOIU Ion1
1University of Medicine and Pharmacy of Craiova, (ROMANIA)
Email: gheorman@gmail.com
Abstract
Introduction
Psychiatric disorders occurring during endocrine dysfunction and, conversely, endocrine
dysfunctions associated with mental disorders were the emergence of a new discipline,
psychoendocrinology. Psychiatric disorders correlated with endocrine diseases are defined as
psychopathological manifestations of variable intensity and clinical symptomatology, determined
by complex psycho-neuro-endocrinological interrelationships. Defining elements consist of the
association between diagnosis of mental disorders and specific symptoms for endocrine
dysfunction.
Methods
We conducted a prospective one-year study (January 2018 – December 2018 on 112 patients
hospitalized in the Clinic of Psychiatry who also had an endocrinological comorbidity. We
investigated the frequency and severity of psychoendocrinological associations by studying a
number of demographic and clinical items.
Results
The results showed that the highest incidence belong to thyroid disorder – 55.36%, followed by
gonadal disorders – 24.11%, and, rarely, pituitary diseases and diabetes. Hyperthyroidism was
associated most frequently with manic episodes, while unipolar depression prevailed in patients
with hypothyroidism. In gonadal disorders, present in majority in female patients (secondary
amenorrhea, menopause or erectile dysfunction in males), depression accompanied by anxiety,
often severe in intensity, was the most frequent psychiatric diagnosis. Psychotic disorders were met
in a smaller number of cases, especially in patients with long history of endocrine disorders and
instability of biological constants.
Conclusions
We may state that affective disorders are the most frequent nosological category in patients with
endocrine dysfunctions. It requires a better collaboration between specialists in endocrinology and
psychiatry, to highlight the determinants which contribute to the development of
psychopathological manifestations in endocrine diseases and to individualize the treatment
depending on cases’ particularities.
Keywords: endocrinology, psychiatry, association
39
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Introduction
Patients with endocrine disorders are more likely to develop psychiatric symptoms of variable
intensity and clinical aspect, especially affective symptoms [1, 2]. For instance, major depression
was frequently found in patients with Cushing Syndrome, Addison Disease, hyperprolactinaemia,
amenorrhea, hyper- or hypothyroidism, or any other thyroid disease [3, 4, 5]. Uncontrolled
diabetes, pheochromocytoma and hyperadrenalism are endocrine and metabolic dysfunctions
frequently associated with anxious disorders, whereas ovarian diseases are often accompanied by
mixed anxious and depressive symptoms [6, 7, 8].
It is sometimes difficult to establish a classification of psychiatric disorders based on the degree
of organic ethiology present in patients with comorbidities, as mental disorders in patients with
medical conditions are frequently found in practice [9]. Patients with endocrine dysfunctions
experience psychiatric symptoms very often. This fact can be explained by a series of factors, such
as: direct physiopathological effects of endocrinopathy, stress experienced by people with chronic
diseases, side effects after a treatment or just a simple coincidence. Along the years, medical
literature has presented few studies discussing the temporal relationship between the onset of
endocrinopathy and the development of mental disorders [10]. In psychiatry, research focused
exclusively on medical situations which challenge the physician by the way they develop, either
by the complexity of these clinical processes, sometimes with high vital risk, or by their symptoms.
Risk factors for pathological diseases determining mental disorders are represented by hypo- or
hyperfunction of the endocrine gland. This highly recommends the study of mental disorder issues
that may arise, eventually at a normal pace during the onset, but if they aggravate, they may lead
to severe impairments [11].
The endocrine system plays an important role in the ontogenetic development of our central
nervous system. Thyroid and sexual hormones are also mandatory items which contribute to brain
development and maturation. Hormones are essential for the brain development, causing general
or local changes in psychiatric functions, influencing the level of neurotransmitters and that of the
cortical anatomic structures [12]. From an anatomopathological angle, the most severe endocrine
dysfunctions trigger brain damage, such as general or local cortical atrophy in various endocrine
diseases [13, 14]. On the other hand, sometimes the endocrine dysfunctions affect the
electroencephalographic activity, showing a correlation between serious thyroid diseases,
panhipopituitarism and functions of the thalamus and hypothalamus [15].
On the other hand, it should be outlined that affective states are some of the factors that have a
substantial impact on the endocrine glands. Central nervous system plays a significant role in the
endocrine system, leading to dysfunctions.
Material and Method
A one-year analysis (January-December 2017) was completed on a study sample consisting of

112 patients with mental disorders, hospitalized in the Psychiatry Clinic of the Craiova who also
had a documented endocrinologic comorbidity. Endocrine diagnosis included obesity, diabetes,
hyper- and hypothyroidism, gonadopathies, hyperprolactinemia. Prior to the inclusion in the study,
patients signed an informed consent. Exclusion criteria were: presence of suicidal thoughts, severe
psychotic symptoms, addiction to psychoactive substances, including alcohol, ongoing pregnancy.
The aim of this study was to establish how frequent and severe were the psychiatric
comorbidities of the subjects, socio-demographic risk factors and endocrino-psychiatric
correlations.
40
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Results
During the study, patients with both mental illnesses and endocrine comorbidities represented
7.2% out of the total of admissions. Sample distribution by age pointed out a substantial prevalence
of endocrine comorbidities in patients over 46 years old – 73.21%, out of which 56.25% were
patients between 46-60 years (Figure 1). The extreme age groups showed a lower incidence of
endocrine comorbidities symptoms.
40 36,61
35
30
25
19,64
20
% 16,07
15
8,048,93
10
3,574,46
5 2,68
0
18-30 yo 31-45 yo 46-60 yo > 60 yo
Male Female
Fig. 1. Sample distribution by gender and age group
Similar distributions on gender can be found in young patients (under 30 years old) and elder
ones (over 60), whereas in most of the cases between 31-60 years old, women were more likely to
develop endocrine dysfunctions, especially around 45 years old, due to the premenopausal period.
The study of the sample revealed the prevalence of thyroid disorders – 55.36%, followed by
gonadal disorders – 24.11% (Figure 2). Metabolic disorders (diabetes, obesity) and
hyperprolactinemia had similar percentage – 9.82%, respectively 10.71%. Regarding the gender
distribution of endocrine dysfunctions, visible differences were found only in the group of thyroid
disorder. The values of the rest of the disorders are similar one to another.
50
43,75
45
40
35
30
% 25
20
15
11,61 11,61 12,50
10
4,46 5,36 6,25 4,46
5
0
Diabetes/Obesity Thyroidian Gonadal Hyperprolactinemia
Male Female
Fig. 2. Sample distribution by gender and endocrine pathology
41
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Mental disorders associated to endocrine dysfunctions were narrowed down and classified into
the following categories: affective (including depression, with or without anxious symptoms and
mania), psychotic (this group including schizophrenia, delirium, acute psychosis) and personality
disorders. If we correlate mental disorders with endocrine dysfunctions, it turns out that depression
seems to be the most frequent diagnosis associated with endocrine dysfunctions, except for the
cases of hyperprolactinemia, where psychotic episodes were more frequent (Figure 3). Therefore,
we are more likely dealing with a reverse cause, because high levels of hyperprolactinemia may
mean side effects of the antipsychotic treatment administered.
Mania was also correlated with thyroid (hyperthyroidism); manic symptoms could also
represent a side effect of the therapeutic use of thyroid hormones. A similar pathogeny can be found
in the presence of manic symptoms from endocrine and metabolic disorders, as it is known that
certain drugs used to control body weight may lead to mood and behaviour disorders, especially if
these substances are not administered under strict medical surveillance. Patients suffering from
thyroid disorders showed psychotic symptoms or personality disorders, to a lesser extent, the latter
being especially present in cases of gonadic (5.36%) and endocrine and metabolic conditions
(3.57%).
As we found many cases of depression, we differentiated this disorder between the types of
endocrinopathies by performing a dynamic evaluation. We assessed the intensity of depressive
symptoms during the period of hospitalization and on a 3-month follow up, using the Hamilton
depression rating scale (HAM-D 17) applied at admission, after a week of hospitalization, at
discharge, after one and three months.
The results of the assessment were different, according to the type of endocrinopathy. This being
said, patients suffering from diabetes/obesity developed a lower level of depression at onset, from
the very first week, so after a long period of linear decrease, they were rated as normal (non-
depressive, HAM-D<7) at the endpoint. In patients with thyroid and gonadal disorders, the
intensity of depressive symptoms, of moderate intensity at onset (close to severe in gonadopathies)
had a slower pace of decrease, with a later improvement, as at endpoint, many patients, especially
with hypothyroidism, still had mild symptoms of depression (Figure 4).
40
33,93
35
30
25
% 20
15,18 16,96
15
8,04
10
5,36 4,46 5,36
5 3,57
0,89 0 1,78 1,78 1,78 0,89 0
0
0
Depression Mania Psychosis Personality Dis.

Fig. 3. Sample distribution by endocrinological comorbidities
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We performed a separate dynamic analysis of items 4, 5, 6 (for sleep disorders), as well as for
items 9, 10, 11 (anxiety/agitations), according to the psychiatric symptoms experienced by most of
the patients. Patients with diabetes/obesity were affected by medium insomnia, waking up
frequently during the night, and most of them had nightmares. We also noticed that sleep disorders
persisted and become acute in patients with diabetes and obesity during their first assessment week.
Patients with thyroid dysfunctions, with initial severe insomnia, had difficulties staying asleep
and were not able to return to sleep when waking up early in the morning (late insomnia). Patients
with gonadal disorders had difficulties in falling asleep (early insomnia). Sleep disorders improved
during the study period, as patients received a specific treatment after psychiatric assessment
(Figure 5).
Patients with thyroid dysfunctions were more likely to experience symptoms of anxiety or
agitation. Evolution of these symptoms was linear, in some cases with the persistence of moderate
anxiety symptoms, observed in gesture and mimics. During the study, anxiety in gonadal disorders,
first manifested by somatoform features, had a positive course; in endocrino-metabolic disorders,
anxiety was highlighted by symptoms of irritability and respiratory somatic symptoms (Figure 6).
25
23
21
19
17
15
13
11
9
7
5
Admission 1 week Discharge 1 month 3 months
Diabetes Thyroidian Gonadal

Fig. 4. HAM-D scoreevolution
5
4,5
4
3,5
3
2,5
2
1,5
1

Fig. 5. HAM-D subscores: insomnia outcome
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A global marker of evolution was represented by a high number of admissions in psychiatric

wards during the study period. All in all, the study sample had a positive evolution, with high
prevalence of one single admission (Figure 7). The sub-group of patients with hyperprolactinemia
proportionally registered a higher rate of hospitalizations for psychotic re-occurrences. It is worth
mentioning the fact that medically induced hyperprolactinemia was totally remitted, in these
patients, when switching to an antipsychotic drug with reduced side effects.
9
8
7
6
5
4
3
2
1

Fig. 6. HAM-D subscores: anxiety/agitationoutcome
30 26,79
25
20
16,07
15 12,50
%
10,71 8,93
10
5,38 4,46 6,25
5 2,68 1,79 1,79 2,68
0
One admission Two admissions 3 or more admissions

Fig. 7. Sampledistributionbyadmissions in psychiatricwards
Conclusions
Psychiatric symptoms in endocrine disease of various types and intensity distinguish themselves
and develop according to the affected endocrine gland, its hypo- or hyperfunction and the specific
drugs used to cure it. Under these circumstances, interdisciplinary collaboration becomes
extremely useful, confirming the benefits of outlining psychoneuroendocrinology as a
transdisciplinary clinical field. This continuously improved collaboration stands for the dynamic
relationship between the two disciplines, by stimulating addressability, by establishing theoretical
foundation in the study area and last, but not least, by shaping an individualized therapeutic
strategy.
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General Nutrition Principles for the Mental and Physical Health of

Children
LUPU Vasile Valeriu1, MIRON Ingrith2, NISTOR Nicolai3, STARCEA Magdalena4,

LUPU Ancuta5*, CIUBARA Anamaria6
1 Paediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, (ROMANIA)
6 “Dunarea de Jos” University, Faculty of Medicine and Pharmacy, Clinical Medical Science Department, Galati, (ROMANIA)
* Corresponding author: LUPU Ancuta
Emails: valeriulupu@yahoo.com, lucmir@yahoo.com, magdabirm@yahoo.com, nistornicolai@yahoo.com,

anca_ign@yahoo.com, anamaria.ciubara@ugal.ro
Abstract
According to the theory of Hipocrates (3rd century BC), “all diseases begin in the intestines”. It
is now known that intestinal microorganisms participate in physiological processes such as:
immune system functioning, detoxification, inflammation, neurotransmitter and vitamin
production, nutrient absorption, hunger and satiety signalling, carbohydrate and fat burning. Thus,
a beneficial microbial flora is maintained by proper nutrition. Also, in the literature, there are
microbiome-specific associations with different pathologies: attention deficit hyperactivity
disorder (ADHD), asthma, autism, allergies, chronic fatigue, depression, anxiety and diabetes. To
prevent these pathologies, in the children’s growth and development it has to be taken into account
multiple factors: the type of birth (natural or caesarean), genetics, general health, physical activity,
sedentarism, sleep quality, and appropriate nutrition.
Keywords: nutrition, health, child, ADHD, autism
Background
According to Hippocrates’ theory (3rd century BC), “all diseases begin in the intestines”. Also,
Russian biologist Ilia Mecinikov (19th century) also claimed that “death begins in the colon”. The
human body is colonized by a large number of microbes such as bacteria, fungi, viruses or protozoa.
The largest number of microbes is found at the gastrointestinal level. These microbes form the
intestinal microbiota. The intestinal microbiota acts in a symbiotic manner, being also beneficial
for its host [1, 2]. Microorganisms of the human body are about 10 times more numerous than own
cells. Intestinal microorganisms participate in physiological processes: immune system
functioning, detoxification, inflammation, neurotransmitters and vitamin production, nutrient
absorption, hunger and satiety signalling, carbohydrate and fat use [3, 4, 5]. A beneficial microbial
flora is maintained by proper nutrition. Also, there are specific associations between the
microbiome and certain pathologies in the literature: Attention Deficit Hyperkinetic Disorder
(ADHD), asthma, autism, allergies, chronic fatigue, depression, anxiety, and diabetes.
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Pathophysiology
The intestinal-brain axis is a biaxial signalling axis between the gastrointestinal tract and the
nervous system. The bowel-brain axis can regulate pain, energy behaviour and metabolism [6].
The three main ways in which intestinal microbes reduce the risk of brain damage are by
controlling inflammation, protecting intestinal wall integrity and producing important substances.
By controlling inflammation, the production of inflammatory compounds in the body and the
brain is limited. It is known that inflammation is the origin of various degenerative diseases of the
human body: diabetes, cancer, coronary artery disease and Alzheimer’s disease. By protecting the
integrity of the intestinal wall and preventing intestinal permeability, the passage of proteins, which
puts the immune system in difficulty and, implicitly, causes the inflammation, is prevented. The
production of important brain health substances (vitamin B12, glutamate neurotransmitters and
GABA) together with the fermentation of substances (polyphenols) that turn into smaller anti-
inflammatory compounds contributes to brain protection [7]. There are studies that have shown
that changes in the intestinal microbiota can control inflammation, endogenous production of GLP-
2 that can cause associated metabolic disorders, thus highlighting the mechanism of microbiota and
the occurrence of metabolic diseases [8, 9, 10].
Dysbiosis Associated with Autism Spectrum Disorders
Autism spectrum disorders are a group of disorders including autism and Asperger syndrome
that manifest in early childhood and are characterized by qualitative abnormalities in social
interactions, communication abilities and abnormal behaviours, restricted repetitive interests and
activities [11]. Behavioural and developmental factors that suggest autism also include: regressive
development, abnormal responses to environmental stimuli, abnormal social interactions, absence
of smile in interaction with parents or other known people, absence of typical responses to pain
and bodily injuries, speech abnormalities, susceptibility to infections and fever, absence of
symbolic play, stereotype behaviour.
The real cause of autism is unknown. Hypotheses include obstetric complications, infections,
genetic factors and exposure to toxins [12, 13]. There are studies demonstrating the implications
of intestinal dysbiosis in the role of pathogenesis of autism spectrum disorders. The intestinal
microbiota and its metabolites affect the central nervous system through the intestine-brain axis
that can communicate with the central nervous system on the neural, endocrine and immune
pathways, influencing brain function and causing aberrant behaviour [14]. Studies performed on
mice have shown that alteration of the intestinal microbiota can result in the synthesis of
neurotoxins that may interfere with non-development, causing changes in brain chemistry and
implicitly in behaviour. Characteristics of autism spectrum disorders such as anxiety, depression
and cognitive dysfunction are determined by neuronal changes associated with bowel dysbiosis
[15, 16]. The important role of the microbiota in the development of autism spectrum disorders is
also underlined by probiotics considered to contribute to the normalization of intestinal microflora,
thereby reducing anxiety and improving cognitive behaviours [17].
Almost all people with autism face gastrointestinal problems: abdominal pain, diarrhoea,
meteorism, intestinal dysbiosis, and increased intestinal membrane permeability [18]. Species of
intestinal bacteria found in people with autism create compounds that affect the immune system
and the brain. Children have a rapidly developing brain and are the main ones that are affected.
Multiple studies have found a decrease in Firmicutes and in beneficial bacteria such as
Bifidobacteria and Prevotella, with an increase in Bacteroidetes and potentially pathogenic
47
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bacteria such as Proteobacteria and Clostridiales [19]. The development of these bacteria seems
to play an important role in the development of autism.
Dysbiosis Associated with other Pathologies
The gastrointestinal tract must remain non-responsive to food antigens and intestinal microbiota,
while being able to respond quickly to invading pathogens. The intestinal microbiota must be able
to limit access of pathogenic bacteria to the intestinal epithelium by competitive exclusion. Also,
intestinal microbiota helps maintain immune homeostasis by stimulating different T-cell response
arms [2].
Inflammatory intestinal diseases (Crohn’s disease and ulcerative colitis) have unknown
aetiologies and a marked incidence in many developed countries. Numerous studies have suggested
the important role of intestinal microbiota in the pathogenesis of inflammatory bowel disease [20].
The intestinal dysbiosis in patients with inflammatory bowel disease involve a decrease in the
intestinal microflora of Firmicutes and Bacteroides. Also, dysbiosis in Crohn’s disease was also
associated with a relative increase in the Enterobacteriaceae family [21].
Obesity is the most common nutritional disorder among children and adolescents in the United
States. Approximately 21-24% of American children and adolescents are overweight, and another
16-18% suffer from obesity. Obesity represents a metabolic disorder involving an excessive
amount of body fat storage being considered a more complicated disease associated with intestinal
dysbiosis in both mice and humans [22].
Diabetes mellitus is an autoimmune disease and is a carbohydrate metabolism disorder
characterized by the inappropriate production or use of insulin, which is needed to convert sugars
and starches into energy for the body to function. Insulin-dependent diabetes mellitus associated
with dysbiosis is characterized by the decrease of degrading bacteria of mucin, Bifidobacteria,
Lactobacillus and Prevotella associated with an increase in Bacteroides and Clostridium [23]. In
contrast, dysbiosis associated with non-insulin dependent diabetes mellitus is characterized by a
decrease in Clostridium, an increase in Lactobacillus and an increase in Bacteroides in case of non-
insulin-dependent diabetes that is not associated with obesity [24].
In Colorectal Cancer patients a general pattern of dysbiosis has been found which involves a
decrease in butyrate-producing bacteria associated with an increase in the proportion of several
pathogenic bacteria (Akkermansia muciniphila and Fusobacterium nucleatum) [25].
The intestinal microbiota can also play an important role in the development of allergic diseases.
The reduced microbial diversity of the intestine in infants has been associated with an increased
risk of developing food allergies at this age. The authors of a study have shown that a lower number
of bacteria such as Bifidobacterium, Akkermansia and Faecalibacterium together with a greater
abundance of specific fungi, including Candida and Rhodotorula in neonates, can predispose to
allergy sensitivity by influencing T cell differentiation [26].
General Principles of Nutrition for a Normal Intestinal Microbiota
At birth, the entire digestive tract is sterile. Initially, the intestine is first colonized by maternal
bacteria at birth and continues to be subsequently populated by means of diet [27]. Factors that
may influence colonization include: gestational age, birth pattern (vaginal birth or caesarean
delivery), health level, and exposure to antibiotics. Vaginal born babies have much higher levels
of bifidobacteria, a group of beneficial intestinal bacteria that contribute to the faster maturation of
the intestinal mucosa. The disadvantages of caesarean delivery are multiple: a five-fold increase in
48
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the risk of allergies, tripling the risk of ADHD, doubling the risk of autism, increasing the risk of
celiac disease by 80%, increasing the risk of obesity in adulthood by 50% and 70% increase in the
risk of diabetes [28, 29].
The intestinal microbial of new-borns has a low diversity and is dominated by bacteria such as
Proteobacteria and Actinobacteria. Subsequently, the microbiota becomes more diverse along
with the emergence of the Firmicutes and Bacteroidetes domination, which characterizes the adult
microbiota [30].
The composition of the intestinal microbiota is influenced by age, socioeconomic and nutritional
status. Undigested dietary components can contribute substantially to microbial metabolism. Food
fibres increase the volume of the stool and are correlated with an increase in the bacterial mass.
Antibiotics or meat consumption from animals that have received antibiotics have the potential
to deeply influence microbiota [31]. Microbiota quality is also affected by the use of non-steroidal
anti-inflammatories, environmental chemicals, or genetically modified foods [32].
Children learn behaviours through observation and participation in activities [33]. The model of
parents and carers is an ideal opportunity to promote positive eating behaviours. Studies have
shown nutritional similarities in mothers and daughters: drinking, eating fruits and vegetables,
eating fats, minerals and vitamins. Family meals are recommended, when children are encouraged
to eat the same healthy diet as their parents [34, 35]. A diet based primarily on fruits and vegetables,
whole grains, skimmed milk and dairy products low in fat, fish and lean meat is recommended. It
is recommended to balance your caloric intake with physical activity in order to ensure normal
growth. It is encouraged to consume fruit and vegetables, to limit the consumption of juices, to use
vegetable oils containing low saturated fats, to consume whole grain bakery products, to the
detriment of the refined ones (white flour), to consume fish, especially of fish oils and reducing
salt intake, including that of processed foods [36, 37].
Changing nutrition results in alteration of intestinal bacteria, thus contributing to microbial
transformation.
Probiotics are living bacteria, most of them gram-positive (Bifidobacteria spp., Lactobacillus
spp., Lactococcus spp., Pediococcus spp.). Generally, they promote the integrity of the intestinal
barrier, prevent bacterial translocation in the intestine, and reduce the inflammatory response. It is
believed that the effects of probiotics may be transient because it has been shown that
administration of Lactobacillus plantarum may lead to an increase in the amount of this bacteria
in the faeces, but not in intestinal biopsy [35, 38].
Conclusions
The intestinal microbiota changes throughout life and plays an important role both in physical
and mental health as well as in the occurrence of diseases. Progress has been made in a short time,
but in-depth studies on the composition and function of intestinal microbiota are still needed to
strengthen this subject. Changes in intestinal microbiota should be considered in case of diseases
such as intestinal inflammatory diseases, autism spectrum disorders, obesity and diabetes mellitus,
colorectal cancer or allergies. It should be taken into account that the alteration of the intestinal
flora can have a significant therapeutic benefit.
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Sexual Dysfunctions in Schizophrenia – A General Overview of

Relevant Clinical Symptoms
MORARU Codrina1, RĂDULESCU Ionuț-Dragoș2, ROȘU Ioana3,

NECHITA Petronela4, CIUBARĂ Anamaria5
1 Psychiatry Resident, Socola Institute of Psychiatry, Iasi (ROMANIA)
4 MD, Phd, Socola Institute of Psychiatry, Iasi (ROMANIA)
5 MD, Phd, professor at University “Dunarea de Jos”, Galati (ROMANIA)
Emails: moraru.codrina@gmail.com, ionut1989dragos@yahoo.com, ioanabojescu@gmail.com, craciunpetronela@yahoo.com,

anamaria.ciubara@ugal.ro
Abstract
Sexuality in schizophrenia has been and still is a taboo subject, difficult to address, from both
the patient and the clinician. Poor communication links are a major non-compliance factor, with
schizophrenia requiring special attention in terms of therapeutic conduct, which requires a thorough
evaluation. By nature of the disease, patients with schizophrenia have a poor ability to form and
support satisfactory intimate relationships. They often lack the psycho-social skills needed to
establish and maintain interpersonal relationships.
Keywords: schizophrenia, sexual disorders, antipsychotic treatment, adverse effects
Schizophrenia is a complex, chronic mental health disorder characterized by a series of

symptoms that appear in its course, such as illusions, hallucinations, disorganized discourse, and
impaired cognitive capacity [1]. Early onset of the disease, along with its chronic pathway, make
it a debilitating disorder for many patients and their families due to faulty treatment and poor
clinician-patient relationship.
As regards the ethiology of the disease, the exact cause of schizophrenia is unknown and
continues to be a factor of interest to researchers. It is, however, accepted that various phenotypes
of the disease arise due to several factors, such as genetic susceptibility and environmental
influences [2, 3].
One of the many explanations for the onset of schizophrenia is that the disorder begins with
intrauterine life [4]. Pregnancy bleeding, obstetric complications, gestational diabetes, emergency
caesarean section, asphyxia, and low birth weight were associated with the late onset of
schizophrenia. The second trimester of pregnancy – which is an essential stage in fetal
neurodevelopment – has been of particular interest to researchers [5]. Infections and excess of
hormonal levels, predominantly stress hormones during this period, have been linked to a doubling
of the risk of developing the disease over the lifetime [6, 7].
Symptomatology present in schizophrenia is classified as positive, negative or cognitive
symptoms. Each symptom is vital for diagnosis because the clinician tries to distinguish
schizophrenia from other psychotic disorders such as schizoaffective disorder, depressive disorder
with psychotic features and bipolar disorder with psychotic features [8]. Characteristic for
schizophrenia are the appearance of major psychopathological manifestations, such as
52
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hallucinations, delirium, illusions, affective disorders, behavioural disorders, disorganization of

personality.
Sexuality in schizophrenia remains at present a difficult topic for the clinician to address because
of emotional and social factors, which leads to inappropriate treatment and possible patient
noncompliance.
By nature of the disease, patients with schizophrenia have a poor ability to form and support
satisfactory intimate relationships. They often lack the psycho-social skills needed to establish and
maintain interpersonal relationships.
However, although there is a high incidence of sexual dysfunction for this category of patients,
many schizophrenic patients have a normal sexual life [9].
Sexual disorders that occur in the schizophrenic population are divided by gender, and there are
two different entities.
Numerous studies have analysed the sexual life and activity of psychiatric patients resulting in
the following conclusions:
Most patients with schizophrenia have decreased thoughts and sexual desire [5].
In a control study, 51 women diagnosed with schizophrenia had significantly decreased sexual
development compared to 101 patients in the control group [10].
60% of schizophrenic patients have never experienced orgasm, compared with 13.4% of the
control group. The study also highlighted the higher incidence of sexual abuse in female patients;
sexual abuse occurred before the onset of pathology, especially during childhood, and after the
appearance of psychotic symptoms [11].
Schizophrenic men have been shown to have sexual dysfunctions as well. Comparing the sexual
function of untreated and treated patients to health controls it was discovered that the untreated
patients reported a greater deterioration in sexual desires, while patients treated with neuroleptics
had greater desire and sexual thoughts but did not experience erection, orgasm and satisfaction –
side effects of antipsychotic drugs. Both groups had a higher incidence of premature ejaculation
and higher masturbation activity than the control group [12].
Another study compared 113 male schizophrenic patients with 104 control patients and found
that the previous group had less sexual interest, sexual activity and satisfaction. However,
schizophrenic patients have reported sexual intercourse more than once a week [13].
While many authors have observed a decrease in sexual function, Akhtar and Thomson, in
describing schizophrenia and sexuality, report a period of hyper-sexuality and promiscuity in
premature and early onset of the disease [14, 15]. A study by Lukoff et al., on men with recent
onset schizophrenia showed that they were sexually active, most of their sexual activity being
autoerotic [16].
Most pharmacological agents used in the treatment of psychiatric patients affect normal sexual
function in a number of patients, both men and women [17]. Psychiatrists should be prepared to
consider drug therapy as a possible ethiology of sexual dysfunction and make a change in the
therapeutic protocol. The impact of psychopharmacological treatment on sexuality can
significantly diminish patient compliance and may endanger the relationship between the patient
and the physician, especially in paranoid patients.
Sexual dysfunction induced by psychotropic drugs is a major cause of treatment failure. First,
neuroleptics possess significant dopamine blocking activity that may interfere with erection.
Animal studies have shown that stimulation of the dopamine receptor system increases sexual
behavior [18]. One study noted that administration of dopamine agonists obtained erections in most
patients and suggested that some cases of impotence were probably related to the central
dysfunction of dopamine. Dopamine blockade is thought to have an inhibitory effect on human
53
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sexual response. Second, many antipsychotics have alpha-adrenergic blocking activity that can
interrupt normal ejaculation and erectile function. The adrenergic system is involved in
vasoconstriction of the cavernous body and penile erectile tissues and helps to mediate ejaculation
[19]. Seagraves claimed that drugs that delay or affect male ejaculation may have a role in delaying
orgasm or produce anorgasmia in females [19].
The increased levels of prolactin in male patients is associated with erectile dysfunction, adverse
effects in female patients being low libido, galactorrhoea, irregular menstrual cycles, and
deterioration of orgasmic function [20, 21, 22]. The cessation of medication usually leads to
complete recovery, if the pharmacological effect is the cause of the sexual problem. Simple dose
reduction may help relieve symptoms. The most commonly reported antipsychotic for sexual
manifestations was olanzapine, risperidone, clozapine, haloperidol and thioridazine. On the other
hand, pharmacological studies highlight the low rate of sexual manifestations in the case of
aripiprazole, quetiapine, and ziprasidone. Adverse effects of antipsychotic medication can be
counteracted by dose reduction, the use of an atypical antipsychotic at therapeutic doses.
The incidence of sexual dysfunction due to side effects of drugs may vary from agent to agent
and, even more important, from class to class of neuroleptics. Typical antipsychotics tend to have
more sexual side effects than atypical antipsychotics. From classical antipsychotics, thioridazine
exhibits the highest incidence of erectile dysfunction and ejaculatory at 33%, whereas clozapine
has a reported incidence of extremely low, less than 1% [23].
Sex education a great impact on the rehabilitation of schizophrenic patients. There are very few
treatment programs for patients that target their sexuality [24]. Sadow and Corman reveal that
sexual education for psychiatric patients is valuable because it gives patients the space to explore
their own opinions and sexual feelings in a safe environment [25, 26]. In their view, the objectives
of sexual education should be: reduce the incidence of sexually transmitted diseases and unwanted
pregnancies, to provide information regarding sexual intercourse, developing intimacy skills.
As exposed by Lukoff et al., there are some appropriate reasons to include sexual education
training in rehabilitation programs [27]:
Patients with schizophrenia are still sexually active individuals due to their condition, and
deserve recognition and validation;
The presence of sexual dysfunction can be considered a significant psychosocial stress because
there are many patients treated with neuroleptics.
Because the ability to cope with the symptoms is affected, sexual function is an important part
that requires a great deal of attention and not to be a stress factor. Also, in some patients, sexual
side effects of pharmacological treatment may be a significant factor contributing to non-adherence
to treatment.
The reproduction rates of male and female patients with schizophrenia are increasing. These
pregnancies are unplanned and undesirable and this is due to the lack of knowledge of contraceptive
methods in psychiatric patients.
There is a need for better clinician-to-patient communication relationship in order to counteract
early side effects of medication, especially side effects related to sexual functioning. This is
possible by adopting special programs that encourage patients with schizophrenia to develop
healthy sexual relationships and at the same time to overcome social isolation, which is known as
a risk factor in relapse.
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REFERENCES
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Part I. J Clin Psychiatry 41: pp. 134±42. 
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women. Arch Sex Behav  13: 555±67.
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patients. J Clin Psychiatry 56: 137±41. 
16. American Psychiatric Association. Schizophrenia and other psychotic disorders. In: Diagnostic and Statistical
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20. Raboch J (1984) Sexual development and life of female schizophrenic patients. Arch Sex Behav 13: 341±9.
21. Jensvold MF, Plaut VC, Rojansky N et al., (1996) Sexual side effects of psychotropic drugs in women and
men. In Psychopharmacology and women: Sex, gender and hormones (eds MF Jensvold, U Halbreich & JA
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22. Siever LJ, Davis KL. The pathophysiology of schizophrenia disorders: perspectives from the spectrum. Am J
Psychiatry 2004; 161(3): pp. 398-413.
23. Miller LJ (1997) Sexuality, reproduction, and family planning in women with schizophrenia. Schizophrenia
Bull 23: 623±35.
24. Seagraves RT (1989) Effects of psychotropic drugs on human erection and ejaculation. Arch Gen Psychiatry
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25. Lukoff D, Gioia-Hasick D, Sullivan G et al., (1986) Sex education and rehabilitation with schizophrenic male
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27. Lukoff D, Gioia-Hasick D, Golden JS, Nuechterlein KH (1986) Sex education and rehabilitation with male
schizophrenic patients. Schizophrenia Bull 12: 669±77.
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Eating Disorders Associated with Mood [Affective] Disorders

DAMIAN Maria-Cristina1, TERPAN Mihai2, CIUBARĂ Anamaria3
1 Resident Physician Hospital of Psychiatry, Galati, (ROMANIA)
2 Ph.D Student at “Dunarea de Jos” University, Faculty of Medicine and Pharmacy (ROMANIA)
3 Professor Anamaria Ciubară Department of Psychiatry, University “Dunarea de Jos” Galati, Iasi, (ROMANIA)
Email: terpan.mihai@yahoo.com
Abstract
Introduction
Eating disorders are mental disorder defined by abnormal eating habits that negatively affect a
person’s physical or mental health. In the last decade hospitalizations, which included eating
disorders increased among all age groups. The assessment of eating disorders associated with
affective disorders has important clinical implications, but the standard psychiatric classification
DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) and ICD-10 (Classification of
Mental and Behavioural Disorders) are limited.
Objectives
The purpose of the current study is to extend the evaluation of this association and to understand
the clinical implications. Also, the purpose of the study is to understand the implications of eating
disorders in Galaţi County.
Method
We conducted a retrospective study on a lot of 147 patients with eating disorders and mood
[affective] disorders, admitted in the Psychiatry Hospital “Elisabeta Doamna” Galati during the
period from 1 January 2019-1 February 2019.For diagnosis, we used criteria from ICD-10
(Classification of Mental and Behavioural Disorders), DSM-5 (Diagnostic and Statistical Manual
of Mental Disorders).
Results
In the period from 1 January 2019-1 February 2019 have been admitted in the Psychiatry
Hospital not total of 1131 patients, of which 147 were diagnosed with mood (affective) disorders,
in this lot of patients, 17(12%) associated disorder and food as well as the independent disorder.
Among these patients, the percentage of women with eating disorders associated with the
affective disorder was 82% and the percentage of men was 18%.
Conclusions
From the results obtained, it can be concluded that women associate more often eating disorders
with mood [affective] disorders. We also observed the poor association between eating disorders
and affective disorders, eating disorders being associated with a high percentage of other
psychiatric disorders, this high percentage is represented by alcohol and substance use, but also by
high-impact diseases such as Alzheimer’s disease and schizophrenia.
Keywords: eating disorders, affective disorder, hospitalizations, clinical implications
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Introduction
Eating disorders are mental disorders defined by abnormal eating habits that negatively affect a
person’s physical or mental health [1]. In the last decade hospitalizations, which included eating
disorders increased among all age groups. Eating disorders are sometimes fatal illnesses that can
cause severe disturbances to a person’s eating behaviour. Common eating disorders include binge
eating disorder, bulimia nervosa, and, less common but very serious, anorexia nervosa [2]. DSM-
V provides diagnostic criteria for pica, rumination disorder, avoidant/restrictive food intake
disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder [1].
The current classification of eating disorders from ICD-10 is failing to classify most of the
clinical presentation and ignores continuities between child, adolescent and adult manifestations;
requires frequent changes of diagnosis to accommodate the natural course of these disorders [3].
Despite the intense research that has examined the possible risk factors associated with eating
disorders, they have not uncovered the exact ethiology of eating disorders, also they have failed to
understand the interaction between different possible causes of eating disorders. [4]
In mood [affective] disorders the main disturbance is represented by a change in mood or affect,
usually to depression (with or without associated anxiety) or to elation [5, 6].
Mood disorders include: Maniac episode, bipolar affective disorder, depressive episode,
recurrent depressive disorder, persistent mood [affective] disorders, other mood [affective]
disorders, unspecified mood [affective] disorder [5]
Medication is used together with nutritional and psychotherapeutic treatments for eating
disorders. Antidepressants are commonly used to treat bulimia nervosa, binge eating disorder can
be treated with antidepressants, medication that diminish appetite. Although for anorexia nervosa
pharmacological studies have not found any medication that have definitive improvement of the
main symptoms [6].
Psychotherapy and medication are often combined in the current practice. Specie treatments are
now available for both manic and depressive episodes [8].
A series of studies indicated increased rates of affective disorders in the families of patients with
anorexia nervosa and bulimia nervosa [8, 9, 10].
Dysregulation of serotonin, a potent neurohormone involved in both mood and appetitive
behaviour, may represent an etiological link and, along with potential disturbances in other
neurotransmitter systems.
Anorexia nervosa affects predominantly young women, bulimia nervosa also affects women
although the age of onset tends to be later in adolescence [11].
Males represent 10 to 15% of cases, it appears that they are more frequently affected by bulimia
nervosa than by anorexia nervosa.
Comorbid psychiatric symptomatology is frequently encountered in patients with eating
disorders, affective symptoms are particularly common.
The significance of depressive characteristic presenting in a majority of patients with eating
disorders was evident in the earlier conceptualization of this disorders as affective subtype [12, 13].
Currently, depressive features are most often viewed as secondary to the eating disturbance and
often become less severe or abate with the treatment and resolution of the bulimic behavioural.
Methods
A non-randomized observational retrospective study was conducted in the “Elisabeta Doamna”

Psychiatric Hospital with a database of 1131 patients out of which 147 patients with eating
57
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disorders and mood [affective] disorders, admitted in the Psychiatry Hospital “Elisabeta Doamna”
Galati during the period from 1 January 2019-1 February 2019. For diagnosis, we used criteria
from ICD-10 (Classification of Mental and Behavioural Disorders), DSM-5 (Diagnostic and
Statistical Manual of Mental Disorders). The data was compiled and analysed using JASP, EXCEL
and PSPP.
Results
In the period from 1 January 2019-1 February 2019 have been admitted in the Psychiatry
Hospital a total of 1131 patients, of which 147 were diagnosed with mood disorders (F30, F31,
F32, F33, F34, F38), in this lot of patients, 17 (12%) associated disorder and food as well as the
independent disorder (F50).
Fig. I. This figure shows us the number of patients presenting eating disorders associated with affective disorders as
well as the total number of patients and those with only affective disorders associated with other diagnoses
Fig. II. This figure shows us the frequency of the main diagnostics
Among these patients, the percentage of women with eating disorders associated with the
affective disorder was 82% and the percentage of men was 18%.
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Fig. III. This figure shows us the percentage of women and men that associate eating disorders
with affective disorders
Discussion
Out of all the discharges over a period of one month 59% of patients had been diagnosed with
mood [affective] disorders, 8% had been diagnosed with eating disorders associated with mood
[affective] disorders and 34% of patients had been diagnosed with eating disorders associated with
diagnoses like schizophrenia or mental and behavioural disorders due to use of alcohol. The study
period is relatively small, so the findings should be evaluated in a longer study for a better
understanding of the association between eating disorders and mood [affective] disorders.
Clearly, more studies are needed to clarify the association link between eating disorders and
mood[affective]disorders. By exploring this link, we could better understand the implication of this
association and provide for our patients with better care and prevent the advanced stages of these
diseases and socio-economic implications.
What is more, we could, through both pharmacologic and nonpharmacologic means start
prevention strategy for these diseases.
Conclusions
From the results obtained, it can be concluded that women associate more often eating disorders
with mood [affective] disorders. We also observed the poor association between eating disorders
and affective disorders, eating disorders being associated with a high percentage of other
psychiatric disorders, this high percentage is represented by alcohol and substance use, but also by
high-impact diseases such as Alzheimer’s disease and schizophrenia.
Certification
The authors report no conflict of interest in the development of this research.
REFERENCES
1. American Psychiatry Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5 th ed.).
Arlington: American Psychiatric Publishing. pp. 329-354. ISBN 978-0-89042-555-8.
2. https://www.nimh.nih.gov/health/publications/eating-disorders/eatingdisorders_148810.pdf
3. Classification of feeding and eating disorders: review of evidence and proposals for ICD-11 RUDOLF
UHER1 and MICHAEL RUTTER2.
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4. Rikani, AA; Choudhry, Z; Choudhry, AM; Ikram, H; Asghar, MW; Kajal, D; Waheed, A; Mobassarah, NJ
(October 2013). “A critique of the literature on ethiology of eating disorders”. Annals of Neurosciences. 20
(4): pp. 157-61. doi: 10.5214/ans.0972.7531.200409. PMC 4117136. PMID 25206042.
5. ICD-10 (Classification of Mental and Behavioural Disorders)
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Am J Psychiatry 1980; 137: pp. 695-698.
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Psychiatry 1983; 142: pp. 133-138.
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Anniversary Depression
MUSCĂ Loredana-Maria1, PLEȘEA-CONDRATOVICI Cătălin2,

CIUBARĂ Anamaria3,4
1 Resident Physician at Psychiatric Hospital “Elisabeta Doamna”, Galați, (ROMANIA)
2 PhD Senior lecturer, Department of Morphological and Functional sciences of Faculty of Medicine and Pharmacy, “Dunarea de
Jos” University, Galați, (ROMANIA)
3 PhD Hab. Professor, Head of Department Psychiatry at Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, Galați,
(ROMANIA)
4 Senior Psychiatrist at Psychiatric Hospital “Elisabeta Doamna”, Galati, Romania
* Correspondence author: MUSCĂ Loredana-Maria
Email: loredanamusca@yahoo.com
Abstract
Introduction
Anniversary depressions are characterized by a dispositional change dominated by sadness,
revolt against “destiny”, regret and often self-accusations and suicidal concerns. They reflect a
close correlation with a stressful event, especially localized during the family lifetime, such as the
death of the child, the parent, partner or other loved ones. Anniversary depression occurs more or
less spontaneously with the approach of the trauma event or even at the anniversary of it. Symptoms
of depression may occur a few days or weeks before and culminate at the anniversary when some
of the depressed guilty feelings are shut down in their own painful intimacy (with high suicidal
risk) and the others revolt against the destiny and “the guilty”.
Aim
The objective of this study is to evaluate young people’s opinions about anniversary depression.
Method
A questionnaire derived from HAM-D (Hamilton Depression Rating Scale) was applied to a
group of 56 students during the year 2019. A quantitative and qualitative assessment of young
people’s perception of depressive symptomatology was evaluated. Applied questionnaires comply
with the privacy rules of Law 46/2003 (A) and EU Regulation 2016/679.
Conclusions
From the investigated group it results than 93% know someone who has experienced a traumatic
episode. Of the 56 examines a significant proportion know or have experienced a traumatic event
with an impact on mood (79%). Behavioural changes associated with the traumatic event or recall
of such an event (in decreasing frequency) are sleeping disorders 79%, mood disorders 77%,
appetite change 48%, somatoform accusations 36%, suicidal tendency 30%, decreasing useful
yields 25 %, feelings of guilt 21%, decrease in alcohol consumption 14%, increase in alcohol
consumption 7%.
Keywords: depression, anniversary, traumatic event, remembrance
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Introduction
Depression is a commonly found disease worldwide, affecting more than 300 million people
worldwide. Chronic depression of mean or increased intensity can have a major negative influence
on the affected person, decreasing its functionality in the workplace, at school or within the family
and the quality of life. 1, 2, 3
The prevalence of depression and other mental illness is on the rise worldwide. In this sense, in
the resolution of the 66th WHO General Assembly, the Comprehensive Action Plan for the
Promotion of Mental Health 2013-2020 4 was adopted, a plan which includes a series of measures
that are encouraged by WHO Member States initiate them to limit the burden of mental illness and
ensure an optimal mental health status among the populations.
Depressive disorders are characterized by sadness, loss of interest or pleasure, feelings of guilt
or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration.
Depression can be long lasting or recurrent, substantially impairing an individual’s ability to
function at work or school or cope with daily life. At its most severe, depression can lead to suicide.
5
It is expected that depression will become the second cause of disability worldwide by 2020 and
it is ranked by the World Health Organization as the fourth leading cause of disability across
nations 6, 7.
Almost all studies found that women have a twofold greater prevalence of major depressive
disorder compared with men and that the highest onset rate of depression occurs between 20 and
50 years 8, 9.
In typical depressive episodes, the subject usually suffers from a depressed mood, loss of
interests and joy, and a reduction in energy that leads to increased fatigue and diminished activity.
A strong fatigue after a little effort is common. Other common symptoms are: reduced
concentration and attention, reduced self-esteem, guilty ideas and lack of value, sad and pessimistic
vision of the future, self-harm or suicide ideas or acts, disturbed sleep and diminished appetite. For
depressive episodes, irrespective of the degree of severity, a minimum of 2 weeks is required to
establish the diagnosis, but shorter times may be accepted if onset is rapid and unusually severe
symptoms. 10
Major depressive disorder has to meet the following diagnostic criteria:
A. Five or more of the following symptoms have been present during the same 2-week period
and represent a change from previous functioning; at least one of the symptoms is either depressed
mood or loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report or observation made by others 2. Markedly diminished interest or pleasure in all, or almost
all, activities most of the day, nearly every day 3. Significant weight loss when not dieting or weight
gain, or decrease or increase in appetite nearly every day 4. Insomnia or hypersomnia nearly every
day 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly
every day 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day 8.
Diminished ability to think or concentrate, or indecisiveness, nearly every day 9. Recurrent
thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide [11, 12, 13, 14].
B. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning C. The episode is not attributable to the physiological effects
of a substance or to another medical condition D. The occurrence of the major depressive episode
62
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is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder,

delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic
disorders E. There has never been a manic episode or a hypomania episode. 15
Anniversary depressions are characterized by a dispositional change dominated by sadness,
revolt against “destiny”, regret and often self-accusations and suicidal concerns. They reflect a
close correlation with a stressful event, especially localized during the family lifetime, such as the
death of the child, the parent, partner or other loved ones.
Anniversary depression occurs more or less spontaneously with the approach of the trauma
event or even at the anniversary of it. Symptoms of depression may occur a few days or weeks
before and culminate at the anniversary when some of the depressed guilty feelings are shut down
in their own painful intimacy (with high suicidal risk) and the others revolt against the destiny and
“the guilty”.
Near the anniversary of the traumatic event or even on the anniversary date, individuals may
experience depressive disorders, but there is a degree of symptomatology depending on exposure
to actual or threatened death, serious injury, or sexual violence in one of the following ways:
directly experiencing the traumatic event or witnessing, in person, the event as it occurred to others;
experiencing repeated or extreme exposure to aversive details of the traumatic event or learning
that the traumatic event occurred to a close family member or close friend. In cases of actual or
threatened death of a family member or friend, the event must have been violent or accidental.
Anniversary depression is influenced by several risk factors including: temperamental – these
include childhood emotional problems and prior mental disorders, negative appraisals,
inappropriate coping strategies and development of acute stress disorder; environmental – these
include lower socioeconomic status, lower education, exposure to prior trauma, childhood
adversity, cultural characteristics, lower intelligence, minority racial or ethnic status and a family
psychiatric history, severity of the trauma, perceived life threat, personal injury, interpersonal
violence, subsequent exposure to repeated upsetting reminders, subsequent adverse life events and
financial or other trauma-related losses; genetic and physiological – these include female gender
and younger age at the time of trauma exposure.15
Methods
A non-randomized observational prospective study was conducted in the “Elisabeta Doamna”

Psychiatric Hospital of Galați. The database was made up of 56 students, with ages between 22 and
54 years, who was applied a questionnaire derived from HAM-D (Hamilton Depression Rating
Scale) during the year 2019. A quantitative and qualitative assessment of young people’s
perception of depressive symptomatology was evaluated. Applied questionnaires comply with the
privacy rules of Law 46/2003 (A) and EU Regulation 2016/679. For diagnosis to depressive
disorder we used criteria from the International Statistical Classification of Diseases and Related
Health Problems 10th Revision (ICD-10) and Diagnostic and Statistical Manual of Mental
Disorders (DSM-5). The collected data was compiled and analysed using JASP version 0.9.2.0,
SOFA Statistics version 1.4.6. and Microsoft Excel version 2010.
For the categorical variables (gender, the environment of origin, age) were estimated the relative
frequency (the reported number to the total number), the absolute frequency (number) and the
central trend. Standard error mean (SEM) was calculated to determine a 95% confidence interval
for the arithmetic mean (CI95%).
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The mean age of the patients was 31,41 (SEM: ±1,35) [CI95%: 30.51 to 32.95] years,
mentioning that the distribution had an important negative skewness (-1.89), the median was 25,5,
standard deviation 10,1, minimum 22 and maximum 54.
The value mean of the feminine gender was 31,36 [CI95%: 28.63 to 34.09], standard deviation
9.74, p-value ˂0.001 (3.775e-6) was statistically significant and for masculine gender the mean
was 31,71 [CI95%: 21.88 to 41.54], standard deviation 13.26.
Group N Mean CI 95%3 Standard Min Max Kurtosis5 Skew6 p abnormal7

Deviation4
28.639 -
F 49 31.367 9.744 22.0 50.0 -1.367 0.529 <0.001 (3.775e-6)
34.096
Unable to calculate
21.889 -
M 7 31.714 13.263 22.0 54.0 -0.942 0.905 overall p for normality
41.540
test
Table 1. Distribution by gender – ANOVA test indicate that there are statistical differences
Fig. 1. Distribution by age and gender
The average distribution of the phenomenon in the rural environment was 27,11 [CI95%: 22.15
to 32.07], standard deviation 7.59, p-value ˂0.001 (2.260e-4) was statistically significant and the
mean in the urban environment was 32.23 [CI95%: 29.26 to 35.20], standard deviation 10.37, p-
value ˂0.001 (1.813e-5) was statistically significant.
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Deviation4
22.152 -
R 9 27.111 7.590 22.0 46.0 2.480 1.922 < 0.001 (2.260e-4)
32.070
29.267 -
U 47 32.234 10.378 22.0 54.0 -1.356 0.460 < 0.001 (1.813e-5)
35.201
Table 2. Distribution by environment of origin – ANOVA test indicate that there are statistical differences
Fig. 2. Distribution by age and the environment of origin
The applied questionnaire, derived from HAM-D, consists of 11 questions.

The first question has the mean value for yes 31.38 [CI95%: 28.64 to 34.12], standard deviation
10.09, p-value <0.001 (8.693e-4) was statistically significant and the mean for no was 31.75
[CI95%: 20.22 to 43.27], standard deviation 11.75.

Deviation4
28.641 -
Da 52 31.385 10.096 22.0 54.0 -1.149 0.642 < 0.001 (8.693e-4)
34.129
Unable to calculate
20.227 -
Nu 4 31.75 11.758 22.0 47.0 -1.393 0.470 overall p for normality
43.273
test
Table 3. Distribution of answers to the first question – ANOVA test indicate that there are statistical differences
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Fig. 3. Distribution of answers by age
The second question has the mean value for yes 32.04 [CI95%: 29.00 to 35.08], standard
deviation 10.28, p-value <0.001 (7.817e-4) was statistically significant and the mean for no was
29.08 [CI95%: 23.72 to 34.44], standard deviation 9.47, p-value 0.2020.

Deviation4
29.008 -
Da 44 32.045 10.280 22.0 54.0 -1.252 0.538 < 0.001 (7.817e-4)
35.083
23.724 -
Nu 12 29.083 9.472 22.0 47.0 -0.706 0.990 0.2020
34.443
Table 4. Distribution of answers to the second question – ANOVA test indicate that there are statistical differences
Fig. 4. Distribution of answers by age for the second question
The third question has the mean value for yes 31.09 [CI95%: 28.00 to 34.18], standard deviation
10.34, p-value 0.01089 and the mean for no was 32.46 [CI95%: 27.25 to 37.66], standard deviation
9.57, p-value 0.04040. The four question has the mean value for yes 37.5 [CI95%: 28.61 to 46.38],
standard deviation 12.81, p-value0.2607 and the mean for no was 30.39 [CI95%: 27.74 to 33.04],
standard deviation 9.36, p-value 6.591e-3. The fifth question has the mean value for yes 31.23
[CI95%: 26.10 to 36.36], standard deviation 10.79, p-value 0.2037 and the mean for no was 31.48
[CI95%: 28.36 to 34.60], standard deviation 9.93, p-value <0.001 (6.118e-5) was statistically
significant. The sixth question has the mean value for yes 34.5 [CI95%: 27.96 to 41.03], standard
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deviation 12.48, p-value 0.04158 and the mean for no was 30.38 [CI95%: 27.62 to 33.13], standard
deviation 9.12, p-value <0.001 (6.384e-4) was statistically significant. The seventh question has
the mean value for yes 32.52 [CI95%: 27.52 to 37.32], standard deviation 10.08, p-value 6.524e-3
and the mean for no was 30.92 [CI95%: 27.72 to 34.12], standard deviation 10.20, p-value 0.03281.
The eighth question has the mean value for yes 40.75 [CI95%: 33.27 to 48.23], standard
deviation 7.63 and the mean for no was 30.69 [CI95%: 27.98 to 33.40], standard deviation 9.96, p-
value 7.905e-3. The ninth question has the mean value for yes 34.81 [CI95%: 30.69 to 38.93],
standard deviation 10.91, p-value <0.001 (5.217e-4) was statistically significant and the mean for
no was 28.24 [CI95%: 25.23 to 31.25], standard deviation 8.26, p-value 0.02501. The tenth
question has the mean value for yes 31.83 [CI95%: 26.00 to 37.65], standard deviation 10.29, p-
value 0.2489 and the mean for no was 31.29 [CI95%: 28.29 to 34.30], standard deviation 10.16, p-
value 4.493e-3. The eleventh question has the mean value for yes 31.55 [CI95%: 26.86 to 36.23],
standard deviation 10.69, p-value 0.1690 and the mean for no was 31.33 [CI95%: 28.09 to 34.57],
standard deviation 9.91, p-value 1.822e-3.
Conclusion
From the investigated group it results than 93% know someone who has experienced a traumatic
episode. Of the 56 examines a significant proportion know or have experienced a traumatic event
with an impact on mood (79%). Behavioural changes associated with the traumatic event or recall
of such an event (in decreasing frequency) are sleeping disorders 79%, mood disorders 77%,
appetite change 48%, somatoform accusations 36%, suicidal tendency 30%, decreasing useful
yields 25%, feelings of guilt 21%, decrease in alcohol consumption 14%, increase in alcohol
consumption 7%.
REFERENCES
1. World Health Organization. Depression – Fact Sheet. [Online]; 2018 [cited 2018 March 22. Available from:
http://www.who.int/mediacentre/factsheets/fs369/en/.
4. World Health Organization. Mental health action plan 2013-2020. 2013. Report No.: 978 92 4 150602 1.
5. WHO. Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health
Organization; 2017. p. 7.
6. Murray CJL, Lopes AD. The Global Burden of Disease: a comprehensive assessment of mortality and
disability disease, injuries, and risk factors in 1990 and projected to 2020. Global Burden of Disease and
Injury Series; v.1. 1996. p. 990.
7. Murray CJL, Lopez AD. Evidence-Based Health Policy-Lessons from the Global Burden of Disease Study.
Science (80-).1996; 274(5288): pp. 740-3.
8. Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioural Sciences/Clinical
Psychiatry. 11th ed. Wolters Kluwer; 2015.
9. Van de Velde S, Bracke P, Levecque K. Gender differences in depression in 23 European countries. Cross-
national variation in the gender gap in depression. Soc Sci Med. 2010; 71(2): pp. 305-13.
10. WHO. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic
guidelines, 1992.
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54, p. 66.
15. DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American
Psychiatric Association, 2013, ISBN 978-0-89042-555-8.
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Dreaming and Parasomnias from a Cerebral Structural View
ELKAN Eva-Maria1, PAPUC Ana-Maria2, GOROFTEI Roxana Elena Bogdan3,

BANU Elena Ariela4, ZLATI Monica5, ALBEANU Adriana Gabriela6,
CONDRATOVICI Alina Pleșea7
1 Senior child neurologist Emergency Children Hospital “Sfântul Ioan” Galați, Asistant at FMF from University “Dunărea de
Jos”, Galați (ROMANIA)
2 Student at FMF From University “Dunărea de Jos”, Galați, III rd Year, Nurse student (ROMANIA)
3 emergency medicine specialists at Emergency Children Hospital “Sfântul Ioan” Galați, Asistant at FMF from University
“Dunărea de Jos”, Galați (ROMANIA)

4 Senior pediatricians at Emergency Children Hospital “Sfântul Ioan” Galați, Associate Professor at FMF from University
“Dunărea de Jos”, Galați (ROMANIA)

5 Military Emergency Hospital “Aristide Serfioti” Galați, PhD student at University “Ștefan cel Mare” Suceava (ROMANIA)
6 Senior child neurologists, PhD – Emergency Hospital for Children Brașov (ROMANIA)
7
Associate Professor at FMF from University “Dunărea de Jos”, Galați (ROMANIA)
Emails: cojocarumariaeva@yahoo.com, anna_maria935@yahoo.com, elenamed84@yahoo.com, banuariela@yahoo.com,
sorici_monica@yahoo.com, adriana.albeanu@yahoo.com, aliaplesea@yahoo.com
Abstract
Introduction
Parasomnias are disorders that may appear during sleep with and/or without dreams. To describe
them we must take in account a subjective description by the patient and his relatives. Objective
measurement of this phenomenology is made with Polysomnography, Electromyography and
Holter EKG.

We searched the recent data about parasomnias in the Medline, Pubmed, Google academic
databases as also in classic books and reviews. Results: The clinical picture is various from motor
and neurological signs to autonomic signs as also sleep related hallucinations. There are more rare
presentations with associated disorders due to excretion and involuntary urinary emission during
sleep disorders. Parasomnias are often preceded by a traumatic event for the patient and his family
members which can be a head trauma or an infection or an intoxication which can be accompanied
by psycho vulnerable events. On the other part parasomnias can be themselves a preamble
announcing neurodegenerative diseases like Parkinson disease, Lewy Body Dementia or some
synucleopathies.
Conclusions
The fluctuations of neurotransmitters (Dopamine, Serotonine or Acetylcholine) due to specific
neurologic pathology can lead to particular parasomnias, their evolution corresponding to each
impairment. The knowledge of accompanying parasomnias of neurologic disorders like those from
Parkinson disease helps manage diseases of neurological patients already known with Parkinson’s
disease or other neurological diseases, leading to increased quality of life for these patients as a
result of specialized intervention.
Keywords: parasomnias, neurotransmitters, neurodegenerative diseases, dream
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Introduction
The sleep state is physiological and has the characteristics of reversibility. The person is not
conscious in this state and from motor point of view the reactions are reduced. [1] The sleep is
composed from sleep cycles with more stages of four types which are NREM sleep called so with
nonrapid eye movements and a stage called REM (rapid eye movement) which are succeeding
more times in a night these cycles varying in length and proportions between different tages of
sleep so they are not identical. After recording we obtain a hypnogram. During REM sleep the EEG
expresses with low voltage and desynchronization. In this stage peoples are dreaming. [2]
Types of sleep disorders

Sleep disorders vary at quantitative level so are insomnias-means few sleep and hypersomnia’s
meaning to much sleep as also in the qualitative way like in parasomnias or mixt where the
circadian rhythm is disrupted. Parasomnias presented in table 1 have a variety of accompanying
phenomena consisting of behaviours and emotional experiences before asleep, during the NREM
sleep or during the sleep with dreams, the REM sleep. [1]
Table 1. Types of parasomnias

Type of parasomnia Sleep stage Characteristics Observations
Isolated sleep paralysis Asleep Conscious but cannot Is included as parasomnia
Before complete move linked to REM sleep Their
awakening can coexist hypnagogic
and-or hypnopompic
phenomena
There can be a hereditary
component.
A person can have a single
episode during life or the
can repeat.
Restless leg syndrome REM sleep disorder Person is not conscious In putamen located iron
Sensorimotor disorder deficiency as also in,
The desire always to move thalamus, caudat nucleus
the legs and substantia nigra
Paraesthesia’s of the limbs Decrease of D2 receptors
in the putemen.
Rhythmic movement Ata awakening The body balances with /or
disorder during sleep without the head and/or
without the limbs
Somnilocvia REM sleep Repeat words of complex
expressions complete
amnesia of episodes
Bruxismus Light stages of NREM The activity of the Destructions of the teeth,
sleep as stages 1 and 2 masticatory muscles is Teeth grinding appear in
watched the REM sleep. Teeth are
protected with special
devices
REM sleep behaviour During REM sleep Rapid movements in sleep Can coexist with major
disorder RBD can affect the patients depressive disorder
during sleep which can announcing a possible
lead to trauma and degenerative disorder.
fractures. At 60-97 years Dopamine is lowered in
the prevalence is 6-7% the striatal neurons. On the
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other hand, the reticular

activates in this disorder
Sleep Enuresis Different stages of Involuntary urine emission Este primar sau secundar,
NREM sleep and during 97-98% din enuresis and este continuu sau
REM sleep non-organic discontinuu în ambele
If both parents have 70% forme, mai frecvent datorat
enuresis that the child will diabetullui, infecţiilro
have urinare dar liu datorită
apneei de somn
Nocturnal paroxistic non-REM sleep Convulsions like episodes
dystonia
Somnambulism REM sleep Amnesia of the episode Can steal objects of
committee crime.
Treatment can consist with
substances used also in
convulsions
anticonvulsants and/or
antidepressives
Nightmare Stage 2 of NREM sleep, The episodes are appearing Can appear in
or REM sleep generally after midnight posttraumatic stress
disorder, or when the
subject is looking before
asleep to horror movies or
games
Nocturnal pavor REM sleep The episodes are finding
place before midnight
generally Lasting for 15
minutes medium. Cannot
communicate
Dissociative disorder in NREM and REM sleep Following or concomitant
sleep with migraines
Catatrenia REM sleep Graoning occurs during Using CPAP machines
expiration in sleep
Hypnagogic at asleep and Stage I sleep and at Can appear also in
hypnopompic at awakening Intoxications, tumours,
awakening hallucinations physiologic
Exploding head syndrome Any stage of sleep or Can appear more times in a
between the stages of month, anxiety is great
sleep
Eating disorder during Stage 4 Ingestions of food and/or
sleep drinks during sleep with or
without amnesia of the
episode
Confuseive awakenings REM sleep Awakes harder Also called sleep
drunkenness
Physiopathology
There are existing two neuronal subpopulations: sleep-on neurons-these neurons have
cholinergic transmission, and a neuronal population sleep-off and their transmission is
serotoninergic and noradrenergic which are located at pontine level. A theory explains how the
dreams appear. Profound respirations will generate a sensation of suffocation or push of the thorax.
These sensations can lead in a next stage to fear but also to visual and auditive hallucinations.
The limbic system is the turntable which modulate the emotions and is activating during REM
sleep. These events were demonstrated with functional studies and it revealed that in the cingulated
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cortex which is part of the limbic system take place the changes which can explain the mood
alterations when REM sleep disorder coexist with depression.[4] In 1999 R. Melzack proposed a
new model of interconnexion of neural networks and this is called by him the neuromatrix. In this
model the cerebral hemispheric surface is connected to the limbic system, under genetic influences.
[9]
Each person has a unique electric signature through the sum of his electrical discharges of the
neurons after the individual electrical model. [10] On the other hand the destruction of the anatomic
pathways involved in the sleep mechanisms can lead to severe alterations of it. So, for example the
pontine infarct determines the reducing of REM sleep as also the NREM sleep. [6] Other diseases
and conditions generating sleep disorders are Arnold Chiari Malformation as also Syringomyelia
and/or Syringobulbia.[6] After location stroke are producing different effects on the sleep, so at the
cerebral hemispheres the stroke produces the inversion of day-night cycle of sleep and in the case
of mesencephalic stroke appear peduncular hallucinations. The nervous system suffers an
asymmetric aging process and the dopaminergic structures from the neostriatum are the first
affected and this phenomenon is more pregnant for the men’s [11, 12, 13, 14]. Because of
degenerative processes the therapeutic response for specific agent groups is modified in time and
the treatment measures will be adequate for each stage of the disease. [15]
Imagistic approach
The white matter can be decreased in volume in the Restless leg foot syndrome.[5] The
dopaminergic pathways at striatal level can be seen with SPECT and PET in the patients with REM
sleep behaviour disturbances disorder. The white matter was investigated with fractioned
anisotropic diffusion tensed images DTI, axial and also radial diffusivity with applied statistics.
Another method is the connecto-metry related to MRI with diffusion. [4] Other imagistic
approaches are voxel-based morphometry, diffusion-based imaging and relaxometry or
transcranial sonography. [5]
In the case of a patient with hypnagogic hallucination 59 years aged, with abulia and anhedonia
we found infiltrative tumour. She made computer tomography native and contrast. Figure 1 a is the
native imagine with digitiform edema and figure 1 b postcontrast computer tomography shows the
infiltrative process.
a b
Fig. 1a. native computer tomography with digitiform edema 1b. Computer tomography with intravenous contrast
substance parieto-occipital right infiltrative process
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Conclusions
The dimension of the parasomnia spectrum must be perceived in the correlation of an integration
process of the neurologic and psychic and psychological functioning, so that the autonomy of the
patient is more and more high so they are self-defeating and perform in everyday life. In figure 4
the dimensions which must be reached by the therapeutic team are the following.
So, it can be seen that in Alzheimer patients 24% of their nights are with involved sleep
disorders. The proportion between different stages of the sleep are different in this patient so the
stage 1 NREM is lasting far more and the REM sleep is disappearing slowly. The processes of the
construction of the entire neuronal network depends on genetic factors but a role is played also by
external influences, so a specific diversity is obtained which is unique for the individualization of
a single person. Adapting the mental health services to the needs of the patients is made by
continuous transformation and dynamization.
REFERENCES
1. Santamaria J., Tolosa E. (2016) Idiopathic rapid eye movement sleep behaviour disorder: diagnosis,
management, and the need for neuroprotective intervention. Review Lancet Neurol 15 (405) pp. 405-19.
2. Cheyne JA., Steve D. Rueffer SD. et al., (1999) Newby-Clark Hypnagogic and Hypnopompic Hallucinations
during Sleep Paralysis: Neurological and Cultural Construction of the Night-Mare Conscious Cogn. 8(3) pp.
319-37.
3. Rizzo G., Tonon C., Testa C., Manners D., et al., (2012) Abnormal medial thalamic metabolism in patients
with idiopathic restless legs syndrome. Brain. 135(Pt 12) pp. 3712-20.
4. Rahmani F., Jooyandeh SM., Aarabi MH. (2018) Microstructural changes in patients with Parkinson disease
and REM sleep behavior disorder: depressive symptoms versus non-depressed Acta Neurologica Belgica
118(3) pp. 415-421.
5. Provini F, Chiaro G. (2015) Neuroimaging in Restless Legs Syndrome. Sleep Med Clin. 10(3) pp. 215-26, xi.
6. Ropper AH., Samuels MA, Klein JP. (2014) Adam’s and Victor’s Principles of Neurology Mc Graw hill New
York p. 407.
7. Anamaria Ciubara https://lapsihiatru.ro/2019/cele-mai-importante-tulburari-de-somn/
8. Dobrescu I.,2010, Manual de Psihiatrie a Copilului si Adolescentului vol2Editura Medica Bucuresti,
Dobrescu I., Rad F. Tulburarile de eliminare Enuresis pp. 443-453.
9. Melzack R. (2001), Pain and the Neuromatrix in the Brain, Journal of Dental Education, 65 (12), pp. 1378-
1382.
10. Victor Iapascurta https://www.researchgate.net/publication/280574650_Pragmatic_Dream_Analysis
11. Băjenaru O. Actualități în diagnosticul și tratamentul bolii Parkinson 2010, Bucureşti Etiopatogenia bolii
Parkinson Szasz Jozsef Attila Etiologie pp. 13-27.
54, p. 66.
15. Băjenaru O. Actualități în diagnosticul și tratamentul bolii Parkinson 2010, Bucureşti, Evaluarea pacientului
cu boală Parkinson Cristina Panea pp. 69-83.
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The Identity of the Psychiatric Patient – Between the Narrative Self

and the Experiential Self
VOINEA Alina.Ioana1, DOBRI Mirona-Letiţia1, ROŞU Ioana1,

1“Socola” Institute of Psychiatry, Iaşi (ROMÂNIA)
2“Dunărea de Jos” University of Galaţi (ROMÂNIA)
Emails: alina_ioana92@yahoo.com, mirona.dobri@gmail.com, ioanabojescu@gmail.com, craciunpetronela@yahoo.com,
anamaria.ciubara@ugal.ro
Abstract
Over the years, psychiatry operated in alliance with various areas of expertise, representing a
frontier before philosophy and neuroscience. Inside these grey dimensions, of crossing between
evidence-based medicine and conceptually subtle features, new trajectories and reckonings were
developed. Therefore, the psychiatric diagnosing process implies an evaluation of the patient and
his disorder through the lens of semiology, of already established criterion, but also an
understanding of the pathological manifestations described in accord with subjective
interdisciplinary experiences. In order to stimulate qualitative approaches in research,
phenomenology proposes an assessment of mental illness with the help of occurrences detailed by
patients, and not only periodically, as exposed by a linear causality. Based on the traditional
outcomes of descriptive psychopathology, we will review the involvement of all these in the
management of adults diagnosed with schizophrenia. The self is the central element of long-
standing perceptual disorders in this disease, difficult findings of a functionally cognitive nature
being reported. Characterized by a narrative divergence, as opposed to conflicting feelings, patients
are not truly captured by a theoretical continuity, but rather in the stances of phenomenology. The
latter build an overview of the pathological identity, stating the necessity of fully understanding
the experiential and profoundly personal stock of the diagnostic procedure. Going forward from
clinical overviews, this presentation launches a dialogue on phenomenological methods and their
impact on the progression of schizophrenia diagnosed patients.
Keywords: schizophrenia, narrative self, experiential self, descriptive psychopathology, phenomenology
Introduction
Psychiatric theory and practice altogether have always been on a changing course, mostly
dependent on the fundamental divergence between the task it has to fulfil and the means it employs.
Trying to observe, diagnose and describe mental disorders making use only of signs and
symptoms, which may well be influenced by other pre-existing conditions of the interested
individual, has proved more than difficult. As the Cerberus was to mythology, so the defining of
psyche studying methods was to the history of psychopathology and it still is, to this day, an
ongoing labour. Psychiatry was never meant to be a medical specialty with its own straightforward
theoretical framework, its design and objectives trespassing various fields of study and merging
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multiple views on mind, brain and, some say, even soul. It is a subject of inexhaustible complexity,
as vast as the range of human behaviour and emotions.
Johann Christian Reil (1759-1813), a German anatomist and physiologist, was a pioneer whose
ideas were remarkably advanced for their time and still have application today. He is remembered
with eponymous descriptions of several anatomical and pathological conditions, including “Reil’s
Islands” of the cerebral cortex, and “Reil’s finger”. But to us, of utmost importance, is the 118-
page treatise he wrote in 1808. [1] In this he defined the newly-formed discipline he called
“Psychiatrie”, later changing it to the term we use today. Reil regarded insanity as a disintegration
or fragmentation of the self. He distinguished three main forces, the disruption of which could
produce mental illness: self-consciousness, awareness and attention. Treatment was directed
towards restoring these. Following publication of Reil’s paper in 1808, the term psychiatry was
globally adopted. By 1810, Nasse was giving lectures on psychiatry at Halle University, the first
such course in the world. In 1820, Heinroth used the term in a book for the first time. Since then,
numerous schools, currents and trends modelled the medical field we witness evolving ourselves.
Psychopathology and the Phenomenological Model
The mental health field, as we already saw, being overturned periodically by scientific
discoveries, new trends and innovative opinions, tends to agree to disagree on a detailed definition
of the central concept of “psychopathology”. That is to say, there was no favourable conclusion
reached in the matter of what criteria need to be met or are enough for a correct use of the term.
Variables such as inability to adapt, tendencies to deviate, functional impairment, irrationality,
weak control of impulses, as well as various combinations of these, have all been advanced by
some proponents as relevant.
Descriptive psychopathology builds itself around the information communicated by the patient
or their relatives, and on what is noted upon examination. It is this that distinguishes the descriptive
approach from other techniques, such as those applied by dynamic psychiatry. For this reason,
compared with other methods, descriptive psychopathology is characterized by a higher degree of
reliability. [2] Descriptive psychopathology, as a method, goes back to Karl Jaspers’ early writings,
summarized in his book “Allgemeine Psychopathologie” (“General Psychopathology”). Today,
description and descriptive psychopathology, however, are used with quite different meanings in
research and practice. The “Oxford Textbook of Psychiatry” launched a thorough and clear
definition, characterizing it as an “objective description of abnormal states of the mind in a way
that avoids preconceived theories.” Clinical data are to be collected in an objective and precise
manner and systematically classified. The authors described Jaspers’ “General Psychopathology”,
published almost a century earlier (1913), as “a landmark in the development of clinical
psychiatry,” observing that the book introduced the methodology in the field of psychopathology.
In the “Introduction” of the first edition of “General Psychopathology”, Jaspers outlined the aim
of the book as follows: “This book gives an overview of the entire field of general
psychopathology, of the facts and various aspects of this science instead of a classificatory system
based on a theory it would like to offer an order based on methodological considerations.” Jaspers
defined phenomenology as the intuitive reproduction (“Vergegenwärtigung”) of “the individual
facts of psychic life present in the consciousness” and highlighted it as a cross-sectional mode of
clinical inquiry. [3]
He also introduced the examiner’s direct, intuitive experience of evidence (“unmittelbares
Evidenzerlebnis”) as a criterion for validity. The aim of phenomenology, defined by Jaspers as
static understanding, is to vividly reproduce the mental phenomena truly experienced by the
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patient, to review their connectivity, outline them with precision, separate them, and label them
according to a specialized terminology. To accomplish this objectively, the examiner needs to
refrain from all theoretical and personal prejudices and suppositions. Diagnoses, too, represent a
form of prejudice, because they tend to bias the examination. For this reason, a suitable diagnosis
should only be given after all the relevant information has been collected. Jaspers recommended,
as a first step in forfeiting all prejudices, “a tranquil immersion into the facts of psychic life without
jumping to conclusions.”
The phenomenological pattern adopted from philosophy and merged with psychiatric
examination methods as a form of understanding psychology (“verstehende Psychologie”),
constitutes the basic undercurrent of descriptive psychopathology. [4] Making use of
phenomenological acquisitions broadened the array of explorative tools in the field of psychiatry,
thus quickly becoming more of a necessity than a mere hypothetical presence. [5] This change can
be exemplified very well through the understanding of delusional phenomenon. It is only under
phenomenological observation that delusion can be revealed in its specificity, as a rupture of
consciousness that is pivotal to what we experience as reality. The scientific recognition of how
experience is manifested is more important and more elucidative than the description and reporting
of its content.
The Truth of the Self
Straying from the names of the renowned physicians, philosophers and psychologists that are
always brought up in discussions regarding the origins of psychiatry as we know it today, we will
draw attention upon a different figure that moulded our field of work, one much more unexpected
– the Elizabethan bard William Shakespeare (1564-1616). Even though it might seem out of place,
or peculiar even, to name the great poet in an article concerning delusional patients, in the first
years of American psychiatry, not one name was cited more regularly than his as an authority on
insanity. [6] He was a central figure in the American Journal of Insanity between 1844 and 1864
and his writings remain evidence of finely tuned, keen observations of the human behavioural
patterns and “madness insightfulness”. That is exactly why we decided to use as a starting point
for this section some of his quotes depicting the crude reality of the psyche, and the way it presents
itself to the world. Jacques’s speech in “As You Like It “(Act II, Scene 2) is quite well known to
begin like this: “All the world’s a stage, and all the men and women merely players; They have
their exits and their entrances; And one man in his time plays many parts (…)” What better phrase
to describe the role of the individual in times scattered with madness and drama? The way
Shakespeare viewed mental illness and its influence on society as he knew it could very well help
us integrate here the focal point of our paper – the narrative self. In Macbeth it stands written: “(…)
life is a tale told by an idiot, full of sound and fury, signifying nothing”. Besides the diseased minds
which challenged the characters of his tragedies, another recurring theme for Shakespeare was this
warped view of life, in which we are all merely passers hoping to catch an opening in one’s story,
just to live out a chapter or two, thus being nothing more than cross-sections of stories. In a tangle
of narrative webs, we can understand, distinguish and identify objects and emotions by surrounding
them with their tale identity, because exactly like selves, they do not exist outside of their imagined
cage. Therefore, this is a story about stories, and more particularly, stories of selves.
Our narrative sense of self is obvious to us not only when strictly thinking of our past and future
or when explicitly engaged in a narrative course of thought. It is also intimately involved in the
way we engage with our environment and in the manner through which we interact with ourselves
and individuals around us. [7] This kind of awareness, more or less conscious by definition, shapes
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our thoughts and feelings about everything and anything. We see other people, and we think of
them, as we do of ourselves, as having a past and a future, so we have a narrative sense of others,
as we do of ourselves. Therefore, our recognition of other people in the surrounding environment
can be traced back to knowing for a fact, about ourselves, that we have a past and a future: a time
we can reminisce about, meaning a sort of autobiography; and a “to be disclosed” moment, that
charges us with planning and making resolutions. [8]
Alisdair MacIntyre (born in 1929), a Scottish philosopher, remarks that a certain behaviour
might defined by “equal truth and appropriateness” as “digging, gardening, taking exercise,
preparing for winter, or pleasing one’s wife”. [9] If we wish to know what an individual is doing
while enacting those, we must understand the links between these various exercises of thought, and
find the strongest, primitive intention, beneath the action. This is made possible by clipping the
behaviour on the frame of connecting stories – “The story of my life is always embedded in the
story of those communities from which I derive my identity. I am born with a past; and to try to
cut myself off from that past, in the individualist mode, is to deform my present relationships. What
I am, therefore, is a key part of what I inherit, a specific past that is present to some degree in my
present.” (Alisdair MacIntyre). Are human brains mere narrative generating machines and
ourselves the protagonists of the narratives they compose?
Jean-Paul Sartre defines the alter self, the experiential one at its core, saying in his “L’etre et le
ne’ ant” (1943): “Pre-reflective consciousness is self-consciousness. It is this same notion of self
which must be studied, for it defines the very being of consciousness.” An experience does not
simply impose, but it is implicitly self-proven, or as Sartre views it, it is ‘for itself’. This feeding
of experience on itself is not merely an instance later acquired, a simple veil, but rather the way
through which consciousness is for itself (“pour soi”), meaning a self-consciousness intrinsic to all
highly functioning beings. [9], [10] When talking about this already given feature of awareness,
though, we must, according to Sartre’s beliefs, steer safe from mistaking it with reflection. The
latter, being firstly a form of representation, is the mechanism through which consciousness aims
its focal point at itself, thus becoming its own subject of consideration. This is a derived action,
splitting the object to be analysed from the self, as if in a much more impersonal or anonymous
way one could see their own soul, for all intents and purposes, in a mirror and judge it in cold
blood. [11]
As we’ve seen while reviewing a short history of psychopathology, we can speak of the self as
the owner of experiences, and the self as the bundle of experiences, two instances so far apart in
theory but moulded together in clinical reality, as we cannot have one without the other. And this
sums up what exactly the concepts of the narrative and the experiential self-represent to psychiatry,
a gateway of sorts into the deepest corners of a patient’s mind, whether you agree to see it from
one point of view or the other.
The Schizophrenic Self-narrative or a “Method to Madness”
The disordered self is viewed as the core disorder of schizophrenia, as stated by the entirety of
basic texts on this disease (from Kraepelin to Minkowski and Schneider). There is a fundamental
“self-world” architecture to every individual, in which we live in the first-person perspective, in
union with our bodies and in interconnectivity to our surroundings, which crumbles in
schizophrenia spectrum disorders. The instance of aware self is, during psychotic breaks,
constantly revised and put to tests, lacking a foundation, thus resulting in alienation and anxiety
birthing experiences. [12] Along with it comes a harshly diminished conscience of a “bodily
subject” and a missing sense of intimacy inside personal, intimate, borders. [13] As depicted by
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literature, narrative usually implies a twofold temporal structure. Firstly, there is a timeframe that
is internal to the narrative itself, a serial order in which one event follows another. This allows for
the composition itself; it is a sort of building block for what stands to be told. While each and every
event composing the story is different and unexpected, at the same time it should be in full
concordance to others linked to it, each being moulded by what was before and imposing on what
will come afterwards, resembling the pieces of a jigsaw. [14] Besides this internal time structure,
a second, external chronology defines the narrator’s temporal connection to the events of the
narrative. Even if this relation is left untold, it is usually at least indicated that what happened was
in the past, or will happen in the future, relative to the narrator’s present. [15] This instance of
temporality depicts a perspective in such a way that the other one cannot, and helps guide the
examiner.
Following the modifications temporal integration suffers, the flow of experiences often breaks
down in schizophrenia. Studies have found evidence for the failure of sensory integration in
schizophrenic experience [16, 17]. Neurologically, temporal integration and self-temporalization
are linked to frontal brain structures. Sequencing events in a way that makes sense is improbable
after suffering frontal lobe lesions, especially in damage to the left frontal lobe. Integration of
experienced content in the time domain, the temporal integration of sensory information
(intermodal binding) in behavioural and linguistic sequences and the proper functioning of working
memory depend on brain activity in the prefrontal cortex. There is good evidence to suggest that
schizophrenia involves just such prefrontal dysfunctions. Schizophrenic patients, compared with
controls, show significantly lower blood flow in prefrontal regions during working memory tasks.
There is evidence from positron emission tomography studies for reduced metabolic rate in
bilateral prefrontal regions in schizophrenics during behavioural performance. [18]
Neuropsychological and neurophysiological studies show similarities of impairments in
schizophrenic patients and in those with frontal lobe damage. Both categories of patients
demonstrate impairments on a variety of cognitive and behavioural tests. It is well noted, however,
that the malfunctioning of the prefrontal cortex necessarily implicates the basal ganglia, thalamus,
brainstem, hippocampal formation and other neocortical areas since the prefrontal cortex interacts
with a complex distributed network. [19, 20]
Other recent results in various neuroscience studies suggest that schizophrenia patients do not
demonstrate a normative self-referential bias. Commonly, our brains process information with a
high self-relevance in a different way than stimuli that are more important to outside occurrences
[21, 22, 23, 24]. This phenomenon – known as the self-reference memory effect – refers to the
comparatively elaborative emotional and cognitive processing given to events with high levels of
self-relevance. [25] In general, bias enables individuals to process self-relevant information in a
more efficient, accurate way – for example, to recognize photographs of their own faces faster and
more accurately than they would be able to recognize the face of another [26]. Compellingly,
studies regarding schizophrenia patients have shown they make more errors than healthy controls
in correctly recognizing pictures of their own faces.
What R.D. Laing wrote in his book, “The divided self” might come to draw a line to all he
studies aforementioned in way in which not much else could: “I am aware that the man who is said
to be deluded may be in his delusion telling me the truth, and this in no equivocal or metaphorical
sense, but quite literally, and that the cracked mind of the schizophrenic may let in light which does
not enter the intact minds (…)”. [27] We, as physicians, might not be able to understand the content
of a patient’s story, not even remotely relating to it, but we must be certain of its authenticity for
the individual’s self.
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Conclusions
Gathering all the detailed information literature has given over past decades regarding this
subject, it becomes quite obvious that, even though it may sometimes reach a too high level of
complexity, truly understanding our patients and their symptoms is not only helpful, but mandatory
for a successful therapeutic process. Observing the mechanisms that contribute to personal
narrative in schizophrenia may also be potentially informative to grasping normative experiences
of consciousness, self, and personal narrative more broadly. In more therapeutic terms, given the
highly individual nature of recovery and healing, the continued exploration of how to include
personal narrative in treatment is of great importance. Lewis Mehl-Madrona, adjunct professor of
anthropology at Johnson State College in Vermont, explained in one of his publications: “how
people change and transform cannot be predicted by knowing the allopathic diagnosis from which
they suffer. How people can heal is implicit within the unique story of their lives and their illness.
We must discover those stories through our interaction and we must co-create a healing future
[…] through the appreciation of the power of story, we can build bridges between the internal and
external worlds to create an integration that allows for far more people to be healed.” (“Healing the
mind through the power of story: The promise of narrative psychiatry”, 2010).
Since the most ancient of times, medicine and storytelling merged in a grey area of existence,
healing and remaining a symbol of protection before all evil entities, imagined or not. Therefore,
we propose a conclusion in favour of understanding, of extending our abilities in the field of our
studies and of learning to trust the self-stories around us, in order to better manage the course of
the therapeutic action we launch. We all are epilogues of our very own intimate stories, and this
stands to prove that we cannot be without what happens to us.
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Falsification and Counterfeiting of Pharmaceutical Products.

Poisoned Elixir – Illegal Contamination of Food Supplements
Recommended in Obesity Control
OVIDENIE Cristina-Elena1, LISĂ Elena-Lăcrămioara2

1 Psychiatric Hospital “Elisabeta Doamna”, Galati, (ROMANIA)
2“Dunarea de Jos” University of Galati, Faculty of Medicine and Pharmacy, Galati, (ROMANIA)
Emails: cristinaovidenie@gmail.com, elena.lisa@ugal.ro
Abstract
In recent years, falsification and counterfeiting of pharmaceutical products has shown a

significant increase, representing a major public health problem, with serious consequences in
terms of both the active substance and the ancillary substances involved.
Generally, people believe that these are “natural” products, which give a false sense of security.
In this context, falsifying food supplements and counterfeiting them by adding illegal substances
mainly refers to weight control products, those with indications of erectile dysfunction and those
that increase strength and increase muscle mass for athletes.
In 2010-2018, as a result of warnings from other states, the Romanian National Agency for
Medicines and Medical Devices (NAMMD) issued warnings about the withdrawal of falsified
products by adding illegal and undeclared substances. At the same time, the National Anti-Doping
Agency (ANAD) publicly presented the list of suspicious fake food supplements, marketed in
pharmacies in Romania and online. Most warnings related to weight loss products containing
illegal and undeclared incriminating substance, sibutramine along with other antidepressants,
benzodiazepines and laxatives.
Since 2014, there has been no information in Romania about the identification of illegally
contaminated products on the territory of the country, although there are still such warnings in
other countries.
Keywords: food supplements, obesity, illegal contamination
Introduction
Counterfeit pharmaceuticals are medicines, food supplements or medical devices that are
produced and distributed with the intention of deceiving/deceiving about their origin, authenticity
or efficacy.
A counterfeit pharmaceutical product may contain inappropriate quantities of the active
substance, or it may be completely absent, can be mistakenly processed by the body, may contain
components that are not authorized (whether or not harmful) or may be supplied in non-conforming
or false packaging and marks [1].
In 2011, according to the World Health Organization (WHO), worldwide drug turnover was
$880 billion, and about 15% of these were counterfeited, and 11 billion were intercepted at the
borders of the European Union non-compliant products. At the same time, it is estimated that more
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than 50% of pharmaceutical products sold on the internet (food supplements and medicines) are
forged [2].
According to statistics, 16% of falsified medicines contain wrong ingredients, 17% are
incorrectly dosed, 60% contain no active substances [3].
Although the factors that lead to the consumption of dietary supplements of plant origin may
vary depending on the demographic and health factors, among others, the information available in
the literature on the characteristics of addictive consumers seems to show that, in general, higher
consumption is found in women, older adults, individuals generally having a high level of
education and a good socio-economic level [4].
In recent years, dietary supplements have increased worldwide, with the majority of the
population putting the same sign between plant and natural, while associating these notions with
the absence of side effects on the body (many consumers perceive them as “healthier” and “safer”
Than medicines) [5]. However, in addition to the risks inherent in the consumption of exogenous
substances, whether natural (such as its own adverse effects and possible interactions of
biologically active phytochemicals with medicinal products), there have been numerous reports of
falsification of dietary supplements already known and traditionally used, or the marketing and
advertising of food supplements, without declaring their actual content [6].
One of these counterfeits involves the illegal addition of synthetic drugs, as it means making
food supplements with faster effects. The most important products in this regard are supplements
for weight control, products with indications for erectile dysfunction and for athletes.
This type of falsification is a major problem of food safety and public health, taking into account
both the massive consumption of dietary supplements and the fact that the population is unaware
of the risks associated with the illegal addition of pharmaceuticals. Procurement of on-line
medicines from unauthorized sources may be a major hazard to the health and life of patients as
the risk of counterfeit products is increased [7, 8, 9].
In fact, for some pharmaceuticals, in the case of low-fat dietary supplements, consumers tend to
stop using these products if they do not have any initial effect. On the contrary, if the counterfeit
supplement succeeds rapidly in achieving the desired results, larger quantities are sold, thereby
increasing the producer’s profit [5].
In search of alternatives to a faster weight loss and avoiding lifestyle changes, people are
increasingly resorting to weight loss products with miraculous effects. As a result, several slimming
products are currently sold with supposed promises of weight loss. Since these products contain
plants or plant extracts, they are often promoted as having “pure natural ingredients”, which are
generally perceived by many consumers as being safe and safe than authorized medicines.
However, they can cause side effects or interact with conventional pharmaceuticals.
Therefore, research conducted in the past decade has focused on the detection of synthetic
substances added illegally in food supplements of vegetable origin, with particular emphasis on
slimming products, for the treatment of erectile dysfunction and athletes.
Materials and Methods
Information on counterfeiting and counterfeiting of pharmaceutical products has been extracted

from current Romanian legislation, scientific articles published on line, news from the media and
from the websites of authorized institutions in Romania, namely the National Agency for
Medicines and Medical Devices NAMM) [10], the National Agency for Consumer Protection
(ANPC) [11], the National Anti-Doping Agency (ANAD) [12].
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Following the analysis of the reporting of this public information, a retrospective descriptive
study was conducted in the period 2010-2018 regarding the warnings issued by NAMM on the
withdrawal of the falsified products on the market, respectively on the public information presented
on the ANAD site during the period 2010-2018 on the list of obesity control products suspected of
tampering, marketed in pharmacies in Romania and on-line.
Pharmaceuticals that have been found to be illegally added to products for weakness include:
appetite suppressants (anorexigenic): sibutramine (a substance withdrawn from the market in 2010
and banned), orlistat, diethylpropion (amfepramone), rimonabant, fenproporex, phentermine and
mazindol; stimulants: ephedrine, norephedrine and synephrine; antidepressants: fluoxetine,
sertraline; anxiolytics: benzodiazepines; diuretics: furosemide and hydrochlorothiazide; laxatives:
including phenolphthalein [13, 14].
In the period 2010-2018, the NAMMD in Romania published on the website a series of warnings
regarding the counterfeiting and counterfeiting of 96 drugs and food supplements present on the
European, Asian and US pharmaceutical markets. Of these, 35 warnings were on pharmaceutical
products with indications in obesity (37%) and 54 counterfeit products for the treatment of erectile
dysfunction (56%) (Fig. 1). A lesser number of warnings (7%) referred to various counterfeit
medicines (Pegasys, Augmentin) or products containing added and undeclared substances such as
non-steroidal anti-inflammatory drugs (diclofenac, indomethacin) and steroids (clobetasol
propionate).
Fig. 1. ANMDM warnings about the falsification Fig. 2. ANMDM warnings about the falsification
of pharmaceuticals during 2010-2018. of some slimming products during 2010-2018.
Distribution by year.
In 2010, a significant number of warnings (10) (Fig. 2) were reported on the marketing of certain
weight loss products and identified as falsified by the illegal and uncleaned addition of synthetic
substances, especially sibutramine. This situation was directly related to the withdrawal from the
market of authorized medicinal products until that time and containing sibutramine as well as a ban
on the use of this substance and was included as of 2010 on the list of substances prohibited by the
World Anti- Doping.
Subsequently, in the years to come, the number of such warnings decreased significantly, with
2012 and 2014 noting their total absence. Starting in 2015, the number of warnings on counterfeit
products outside Romania has started to increase, and in 2017 and 2018 it will be equal to the
number of warnings in 2010 that is worrying about the safety of the world's population.
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Most NMMD warnings during 2010-2018 referred to weight loss products marketed in
Dammarca (12 products), followed by Spain (6 products) and the USA (4 products), while
Portugal, Switzerland and Mexico have warned of a single slimming product as forged (Fig. 3).
The most commonly used substance as adulterant in authorized weight-bearing products was
sibutramine (Fig. 4). Other substances incriminated as being used to falsify these products were
also in the class of antidepressants (fluoxetine), benzodiazepines (diazepam), laxatives
(phenolphthalein).
Fig. 3. ANMDM warnings about the falsification of Fig. 4. Synthetic substances illegally added to the
some slimming products during 2010-2018. slimming products identified outside Romania
Country breakdown during 2010-2018
The National Anti-Doping Agency being the national authority for the supervision and control of
the prohibited substances, at the request of the Customs Directorates, importers and ANPC,
analyses to detect unlawfully and undeclared substances added to a category of products suspected
by the authorities to confirm the presence or otherwise of prohibited substances. 36 products for
weight loss were analysed during the period 2012-2016, which was requested both by the
competent authorities (ANPC, Border Police, Customs Offices through the County Department for
Excise and Customs Operations and the Regional Directorate for Excise and Customs Operations,
ANAD) as well as companies that have marketed those products.
Most analytical requests for products with suspicion of falsification and marketed on Romanian
territory were recorded in 2012 and 2013 (16 products and 14 products respectively) (Fig. 5). In
2014, there was only one request and in 2016 no analysis of any such product was requested. Most
of the slimming products identified as counterfeit by the illegal addition of synthetic substances
were in 2012 (10 fake products identified), followed by a significant decrease in the number of
falsified product identifiers, reaching from 2014 to 2016 not to identify any such products (Fig. 6).
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Fig. 5. The annual distribution of slimming products Fig. 6. Slimming products detected by ANAD in the
marketed in Romania and analyzed by A.N.A.D. Romania as being counterfeit with synthetically
(2010-2018) added substances illegally
In Romania, there is also a marked decrease in the presence of counterfeit products as a

consequence of the ban on sibutramine in these products, a more rigorous control by the authorities
and, to a certain extent, the awareness of consumers and importers on risks, due to the mediatization
on a large scale. No information is available after 2016 on the presence of products for weight
control identified as being falsified in Romania.
This situation can be explained by the fact that sibutramine was the substance that has been
identified in most cases of weight loss products as an illegal substance added to their composition.
All medicines for the treatment of obesity with sibutramine as active substance were withdrawn
from the market in 2011, and it is therefore possible to accept the assumption that products
containing sibutramine on the market were found in the near future (2012-2013). Since 2014, the
number of counterfeit products identified on the Romanian market has dropped considerably, one
of the reasons being the multitude of new generation weakening products on the pharma market
and different from those marketed in 2009-2011, both from the point of view the composition of
plant extracts and the brands involved in the production of weight loss supplements.
Conclusions
Counterfeiting and counterfeiting of medicines is a complex global problem and has been on
the rise in recent years. Counterfeiting drugs is a major public health problem, officially
unrecognized in scale, with serious consequences for the health of the population, directly affecting
mortality and morbidity.
Weight loss products are marketed all over the world in various ways: pharmacies, drugstores,
supermarkets, online and media. Although in other countries there are still warnings about the
existence of counterfeit pharmaceuticals in the pharmaceutical market, however, in recent years
there has been no information in Romania about the identification of illegally contaminated
products on the territory of the country. This finding can be justified by more rigorous control by
authorities but also by changes in brands involved in producing supplements for obesity control.
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REFERENCES
1. DIRECTIVE 2011/62/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 8 June 2011
amending Directive 2001/83/EC on the Community code relating to medicinal products for human use, as
regards the prevention of the entry into the market of falsified medicinal products legal supply; The Official
Journal of the European Union.
2. Pantea, M., Purdel, C., International and European Institutions with Responsibilities in the Field of
Prevention and Counterfeiting of Medicines, Criminal Investigation Magazine VII/Number 2/2014.
3. Wheatley VM, Spink J. 2013. Defining the public health threat of dietary supplement fraud. Compr. Rev.
Food Sci. Food Safety 12: pp. 599-613.
4. “Half of the medicines bought online are counterfeited”, http://sanatateabuzoiana.ro, accessed on 03.03.2019.
5. “Talk to a Drug Trader: Everyone Sells You Illusions!”, Http://www.prosport.ro, accessed 03.08.2017.
6. Superslim weight-loss products withheld from the market because of their amphetamine content. Available
(in Romanian language) at http://www.antena3.ro/romania/produselede-slabit-superslim-retrase-de-pe-piata-
din-cauza-continutului-de-amfetamina-73141.html
7. Lupu, V. V., Ignat, Ancuta., Paduraru, Gabriela, Ciubara, A., Ioniuc, I., Ciubara, A. B., ... & Burlea, M.
(2016). The study of effects regarding ingestion of corrosive substances in children. Rev Chim, 67, pp. 2501-
3.
10. http://www.anm.ro/ accessed 15.03.2019.
11. http://www.anpc.gov.ro/ accessed 15.03.2019.
12. List of analyzed products, http://anad.gov.ro, accessed 04.08.2017.
13. Cohen PA, Benner C, McCormick D. 2012. Use of a pharmaceutically-adulterated dietary supplement, Pai
You Guo, among Brazilian-born women in the United States. J Gen Intern Med 27: pp. 51-6.
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Dual Diagnosis. Alcohol Consumption Associated with Depressive

Spectrum Disorders
DARIE Cristina1*, TERPAN Mihai2,3, SARBU Fabiola1,3, CIUBARA Anamaria2,4

1 Resident psychiatrist, Hospital of Psychiatry “Elisabeta Doamna”, Galati, (ROMANIA)
2 Psychiatrist, Hospital of Psychiatry “Elisabeta Doamna”, Galati, (ROMANIA)
3 PhD Student, University “Dunarea de Jos”, Galati, (ROMANIA)
4 Professor, Department of Psychiatry, University “Dunarea de Jos”, Galati, Iasi, (ROMANIA)
* Correspondent author: DARIE Cristina
Email: cristina.darie27@yahoo.com
Abstract
Introduction
According to studies, a quarter of people who drink alcohol, suffer at least, one depressive
episode, in their lifetime. It has also been found, that one-third of people with depression, are
abusively consuming psychoactive substances, such as alcohol, as a form of self-healing.
Aim
Through this retrospective study, I propose to statistically estimate the association, between
mental and behavioural disorders due to alcohol and depressive spectrum disorders.
Method
The retrospective study was conducted on a group of hospitalized patients, between January 1st
and June 30th, 2018, at “Elisabeta Doamna” Psychiatric Hospital, in Galati, Romania.
For diagnosis, the ICD-10 (Classification of Mental and Behavioural Disorders. Clinical
description and diagnostic guidelines) diagnostic criteria and psychometric tests, such as HAM-
D (Hamilton Depression Rating Scale), AUDIT (test for alcoholism) were used. Patients have
been selected who have matched the association, between mental and behavioural disorders due to
alcohol and depressive spectrum disorders.
Results
Of all 6316 hospitalizations, between 1st January and 30th June, year 2018, a quarter of them,
respectively 24.79% (1566 patients), were diagnosed with alcohol-related disorders and 5.4% (341
cases) with a dual diagnosis, disorders related alcohol associated with depressive elements. During
this 6-month period, of all cases of alcohol-related disorders, it was found that approximately 22%
of them were found with dual diagnosis, respectively, the association of alcohol-related disorders
with depressive spectrum disorders/depressive elements.
Conclusions
Unfortunately, it is estimated that by 2020, depression will become a secondary cause of
disability, worldwide, after cardiovascular disease. According to WHO (World Health
Organization) this disease affects more than 320 million people worldwide, and it’s association
with alcohol abuse is alarming.
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Therefore, patients with dual diagnosis require a multidisciplinary therapeutic approach to

reduce or even neutralize the adverse consequences that may occur in the psycho-social, medical,
family, economic or behavioural context.
Keywords: psychiatry, depression, alcohol, dual diagnosis
Introduction
Psychiatric medical practice reveals illnesses such as alcohol and depression as two of the most
common disorders that affect mental health. In this regard, the association of these two diagnoses,
has a major impact on life and causes the patient to be treated. Alcohol consumption can lead to an
increase in depressive symptoms, a more frequent and severe depressive episode, and a greater
predisposition towards suicidal ideation [1, 2]. Antidepressant medication is far less effective if, in
parallel, there is also alcohol dependence.
How common is Dual Diagnosis?

For example, according to a 2014 National Survey on Drug Use and Health, 7,9 million people
in the U.S. experience both a mental disorder and substance use disorder simultaneously.
Alcohol use disorders and co-occurring psychiatric illness

The co-occurrence of alcohol use disorders with other psychiatric disorders, has been widely
recognized. [3] One disorder may substantially influence the onset of the other, such as when an
individual begins to use alcohol to cope with psychiatric distress. The “dual diagnosis” patient can
be challenging as he or she may not respond as well to standard addiction treatment, and may have
greater rates of relapse, attrition, and readmissions. However, if a co-morbid psychiatric disorder
is found, determining the relative onset of the two disorders may have clinical significance, since
primary disorders tend to be of greater long-term clinical significance. [4]
Aim
There is a profound connection between depressive disorders and alcohol consumption, and this
guides us towards the following dilemma: regular alcohol consumption may predispose people to
depression, or depressed people are more prone to alcohol? Both versions are valid.
Through this retrospective study, I propose to statistically estimate the association, between
mental and behavioural disorders due to alcohol and depressive spectrum disorders.
Depression and public health

Depressive disorders are quite important, from a public health perspective, as they are common,
they may significantly impair psychosocial function, and they have effective interventions [4]. The
impact of these conditions on patients and their families is highly substantial, and they are
considered as one of the major factors contributing absenteeism in the workplace. [1, 5, 6]
Method
The retrospective study was conducted on a group of hospitalized patients, between January 1st
and June 30th, year 2018, at “Elisabeta Doamna” Psychiatric Hospital, in Galati, Romania. For
diagnosis were used the ICD-10 (The ICD-10 Classification of Mental and Behavioural
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Disorders. Clinical description and diagnostic guidelines) and psychometric tests, such as HAM-
D (Hamilton Depression Rating Scale), AUDIT (test for alcoholism). Patients have been selected
who have matched the association, between mental and behavioural disorders due to alcohol and
depressive elements/depressive spectrum disorders. For the statistical interpretation of the data, I
have used the following programs: Microsoft Excel 2010, Epi Info 7 (a public domain suite of
interoperable software tools designed for the global community of public health practitioners and
researchers), JASP Statistics (an open-source statistical program), SOFA Statistics (an open-source
statistics, analysis & reporting software).
Results and Discussion
Of all 6316 hospitalizations, between 1st January and 30th June, year 2018, a quarter of them,
24.79% (1566 patients), was diagnosed with alcohol-related disorders.
Of these 1566 cases diagnosed with alcohol consumption, 341 cases of “dual diagnosis” were
found, respectively 5,4% from total number of studied cases, and 21,78% from alcohol related
disorders diagnoses. These 341 cases include alcohol related disorders and depressive spectrum
disorders (Fig. 1, Fig. 1.1). Of these 1566 cases, with alcohol-related diagnosis, 85.76% (1343
patients) has the primary diagnosis of hospitalization and 14.24% (223 patients) has the secondary
diagnosis of patients admitted for alcohol-related disorders.
percentage of dg with alcohol)
Dual Diagnosis female urban
Dual Diagnosis female rural

Diagnosis related to alcohol
(number & percentage from

Dual Diagnosis male urban
Dual Diagnosis (number &
Dual Diagnosis (number &
Dual Diagnosis male rural

percentage of total cases)
Total number of patients
alcohol diagnosis)
alcohol diagnosis)
alcohol diagnosis)
alcohol diagnosis)
consumption
6316 1566 341 341 77 194 13 57

100% 24,79% 5,4% 21,78% 4,92% 12,39% 0,83% 3,64%
Fig. 1. Distribution of diagnoses (alcohol related, depressive spectrum, dual diagnosis)
Fig. 1.1. Graphics Distribution of diagnoses (alcohol related, depressive spectrum, dual diagnosis
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During this 6-months period, of all cases of alcohol-related disorders, it was found that
approximately 22% (341patients) of them presented “dual diagnosis”, namely, the association of
alcohol-related disorders with depressive spectrum disorders/depressive elements.
Gender and F10.0 F10.1 F10.2 F10.3 F10.4 F10.5 F10.8

residence
Female 28 9 4 19 2 0 27
Male 46 36 66 69 3 1 30
Urban area 63 39 47 62 3 1 2
Rural area 11 6 23 26 2 0 5
Fig. 2. Distribution of alcohol related disorders, by gender and residence
According to ICD-10, Mental and behavioural disorders due to psychoactive substance use,
have the following codes, from F10 to F19.
Figure 2; Figure 2.1; Figure 2.2
F10.0= Acute intoxication; F10.1=Harmful use; F10.2=Dependence syndrome;
F10.3=Withdrawal state; F10.4=Withdrawal state with delirium; F10.5=Psychotic disorder;
F10.8=Other mental and behavioural disorders [7]
Fig. 2.1 Graphics distribution of alcohol related disorders, by gender

F10.0, female, acute intoxication↑↑↑
F10.3, male, Withdrawl state↑↑↑
Fig. 2.2 Graphics distribution of alcohol related disorders, by residence

F10.0, urban, Acute intoxication↑↑↑
F10.8, rural, Withdrawl state↑↑↑
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Depressive
Residence F32 F32.1 F32.2 F34 F34.8 F38 F41 F41.2 F43 F43.2
elements
and gender
Urban 147 6 3 2 1 4 70 5 13 4 18
Rural 26 2 0 0 2 4 25 0 8 0 3
Female 67 0 2 2 0 2 9 0 4 0 6
Male 106 8 1 0 3 6 86 5 17 4 15
Fig. 3. Distribution of depressive spectrum disorders, depressive, anxiety or stress elements, by residence and gender
According to ICD-10, Mood (affective) disorders have the following codes, F30-F39, and
Neurotic, stress-related and somatoform disorders have the following codes, F40-F48.
Figure 3; Figure 3.1; Figure 3.2
F32=Depressive episode, F32.1=Moderate depressive episode; F32.2=Severe depressive
episode without psychotic symptoms; F34=Persistent mood [affective] disorders; F34.8=Other
persistent mood [affective] disorders; F38=Other mood [affective] disorders; F41Other anxiety
disorders; F41.2=Mixed anxiety and depressive disorder; F43=Reaction to severe stress, and
adjustment disorders; F43.2=Adjustment disorders. [8]
Fig. 3.1 Graphics distribution of depressive spectrum disorders, anxiety, stress or depressive elements, by residence
Fig. 3.2 Graphics distribution of depressive spectrum disorders, anxiety, stress or depressive elements, by gender
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Conclusions
The prevalence of depression among alcohol-dependent persons is high. [9, 10] Unfortunately,
it is estimated that by 2020, depression will become a secondary cause of disability, worldwide,
after cardiovascular disease. According to WHO (World Health Organization), this disease affects
more than 320 million people worldwide, and its association with alcohol abuse is alarming. There
is recovery from depression after alcohol detoxification and rehabilitation, and majority of the cases
do not necessarily require treatment for the depression.
In addition, persons that are depressed have a significantly higher craving for alcohol after
detoxification and rehabilitation. It is important to screen for depression and evaluate to determine
the treatment needs during detoxification and rehabilitation. [9]
Therefore, patients with dual diagnosis require a multidisciplinary therapeutic approach to
reduce or even neutralize the adverse consequences that may occur in the psycho-social, medical,
family, economic or behavioural context.
REFERENCES
1. Donohue JM, Pincus HA: Reducing the societal burden of depression: a review of economic costs, quality of
care and effects of treatment, Pharmacoeconomics 25(1): pp. 7-24, 2007 (US National Library of Medicine
National Institutes of Health).
3. Kessler RC, Crum RM, Warner LA, et al., Lifetime co-occurrence of DSM-III-R alcohol abuse and
dependence with other psychiatric disorders in the National Comorbidity Survey, Arch Gen Psychiatry 54(4):
pp. 313-321, 1997.
5. Theodore A. Stern MD, Jerrold F. Rosenbaum MD, Maurizio Fava MD, Joseph Biederman MD, Scott L.
Rauch MD.: Massachusetts General Hospital Comprehensive Clinical Psychiatry, Publisher: Mosby; 1st
edition (May 6, 2008)
7. Benjamin J Sadock, Virginia A. Sadock, Dr Pedro Ruiz MD: Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioural Sciences/Clinical Psychiatry, 11th edition.
8. World Health Organization webpage: http://www.who.int/en/
9. Mary W. Kuria, David M. Ndetei, Isodore S. Obot, Lincoln I. Khasakhala, Betty M. Bagaka, Margaret N.
Mbugua, Judy Kamau: The Association between Alcohol Dependence and Depression before and after
Treatment for Alcohol Dependence, ISRN Psychiatry. 2012.
54, p. 66.
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Pharmacological Add-On Treatments in Managing Antipsychotic-

Induced Weight Gain
RĂDULESCU Ionuț Dragoș1, DOBRI Mirona Letiția1, MORARU Codrina1,

NECHITA Petronela1 ⃰, CIUBARA Anamaria2
1 “Socola” Institute of Psychiatry, Iași, (ROMANIA)
2 “Dunărea de Jos” University of Galați, (ROMANIA)
* Corresponding author: NECHITA Petronela
Emails: ionut1989dragos@yahoo.com, mirona.dobri@gmail.com, moraru.codrina@gmail.com, craciunpetronela@yahoo.com,

anamburlea@yahoo.com
Abstract
Introduction
One of the most common antipsychotic (AP) related adverse drug reaction is weight gain, with
a large proportion of first-episode schizophrenia patients gaining significant weight after receiving
AP treatment and.
Aim
The objective of this study is to put in perspective the current possibilities, in limiting weight
gain through pharmacological supplementation, in patients who are treated with AP medication.
Method
A literature review of PubMed/MEDLINE databases within the date range of January 2015 to
February 2019 was conducted. Focusing primarily on studies that directly analysed body weight
change of patients receiving AP medication supplemented with different pharmacological add-ons.
The primary author completed the selection of studies, data extraction and synthesis and the
assessment of the potential for bias, was carried out by the co-authors. A total number of 1229 of
search results were obtained, from which 14 eligible articles were identified and reviewed. We’ve
focused our attention upon several meta-analysis that compared several classes of drugs like: anti-
obesity drugs, anti-diabetics, gastrointestinal agents, anticonvulsants and appetite suppressors; to
placebo in preventing or reducing weight gain in patients treated with AP.
Conclusions
Maintaining a balanced weight has a major impact on the patient’s quality of life. Weight gain
not only has a serious effect on physical and mental health, but also limits the patient adherence to
treatment. There are a multitude of treatments that are available and effective in managing
antipsychotic induced weight gain. Among them we find Topiramate and Metformin to be the most
efficient when compared to placebo as they are also well tolerated in the short-term period. Higher
quality and larger studies are needed to further this research.
Keywords: Weight-gain, antipsychotics, add-on treatments
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Introduction
Patients with Schizophrenia and other related disorders have a far smaller life expectancy.
Excluding suicide as a cause of early death, mortality in schizophrenia is 1.5 times that of the
general population which can be attributed to cardio-vascular disorders, that are unrelated to the
primary medical condition. (1) The main risk factors for these disorders are increased smoking,
obesity, metabolic syndrome and in consequence diabetes. (1), (2)
Schizophrenia is a severe and chronic illness which alters a person’s behaviour and capacity to
think and fell. Although antipsychotics (AP) are the first line therapy in schizophrenia spectrum
disorders, only 50% of patients respond and remit to AP monotherapy. More often than not there
is a need for adjunctive strategies to raise efficacy, causing an increased side effect spectrum. AP
are associated with multiple side effects, like weight gain and metabolic syndrome. (3) Studies with
AP naive patients are the most revealing on the capacity of a specific AP to produce weight gain
(4). More than 75% of first episode schizophrenia patients experience significant weight gain,
which often reduces treatment adherence drastically (5).
One of the first large scale meta-analysis to study weight gain in patients treated with AP was
Allison et al., in 1999. The results of this study caused a systematic shift in how trials regarding
AP treatments were conducted, and attention to weight gain became the norm. (3) Effects on weight
and Body Mass Index (BMI) progress over time with the duration of AP use being an important
risk factor. The main explanation at that time was based on changes with appetite and food intake,
caused by interactions with the serotoninergic, histaminergic and dopaminergic pathways. (1)
Other factors have been brought into light such as genetics, with polymorphisms of the 5-HT2c
receptor (Rc) and H1, H3 histamine Rc affinity, environment and lifestyle choices of Schizophrenic
patients. (5)
The aim of the current study was to put in perspective more robust evidence regarding modern
possibilities and overall efficiency of add-on pharmacological treatment in reducing and preventing
weight gain in schizophrenic patients treated with AP.
Methods and Results
The primary author completed a literature review of PubMed/MEDLINE databases within the
date range of January 2015 to February 2019. The primarily focus was on meta-analyses that
compared body weight changes of patients receiving AP medication while supplementing with
different pharmacological agents or non-pharmacological interventions.
The search terms included (“meta-analysis”) AND (“antipsychotics” OR “AP”) AND
(“schizophrenia”) AND [(“weight gain” OR “obesity”) OR (“BMI change” OR “Body Mass
Index)]. We searched the reference lists of all included articles.
A total number of 1229 of search results were obtained, from which 14 eligible articles were
identified and reviewed. The primary author completed the selection of studies, data extraction and
synthesis and the assessment of the potential for bias, was carried out by the co-authors. Out of the
14 meta-analysis, 3 reviewed the effects of Topiramate in preventing AP-induced weight gain, 2
of Metformin, 1 the effects of Glucagon-like peptide-1Rc agonists, 2 reviewed non-
pharmacological interventions, 1 reviewed the effects of Metformin with non-pharmacological
interventions and 2 reviewed multiple other agents and non-pharmacological interventions; also 2
meta-analysis that reviewed the risk to experience weight gain associated with a certain AP and 1
meta-analysis reviewed pharmacogenetics.
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Risk Assessment and Pharmacogenetics
Patients with schizophrenia have a considerably higher risk than the general population of
cardiometabolic morbidity. Atypical antipsychotics drugs contribute to that risk through their
weight gain effects. Jacob Spertus et al., published a meta-analysis in 2018 of 14 randomized
clinical trials with 5923 patients, to assess the effect of specific second-generation antipsychotics
on weight gain compared to placebo. Weight gain defined as at least a 7% increase in body weight.
The study showed that the probability to experiencing excessive weight gain increased on
average by 12.6% when a subject was treated with olanzapine, 6% for Risperidone and 4.6% for
Paliperidone. (6)
Cenk Tek et al., 2016 meta-analysis reviewed 28 eligible studies with 52 appropriate treatment
arms with a total number of patients equal to 4139 (2594 male, 1545 female). Comparing risks of
weight gain with different AP in correlation with treatment duration for first-episode psychosis
patients. For the short-term results (≤12 weeks) the analysis of the selected studies showed an
overall mean weight gain difference between AP and placebo to be 3.22 kg. Only Ziprasidone did
not cause significant weight gain in the short-term.
The results for long-term (>12 weeks) treatment observed a significant increase in overall mean
weight difference with 5.30 kg between AP and placebo. The highest weight gain compared to
placebo was observed for Olanzapine with 9.34 kg and Clozapine with 7.19 kg. AP medications
were associated with less weight gain in Asian samples when compared to Western samples.
Excluding a few AP medications, most were associated with significant weight gain for early
psychosis patients, even with a short duration of treatment. (1)
Weight gain is a variable adverse effect of AP treatment, genetic factors play an important role
in mitigating this. Association studies found multiple genes associated with obesity, but an
inclusive pharmacogenetics study of AP-related weight gain is missing.
Jian-Ping Zhang et al., investigated in 2016, 38 single-nucleotide polymorphisms (SNPs) in 20
genes or genetic regions from 6770 patients. These SNPs were distributed in 15 chromosomes that
have been documented to have associations with antipsychotic-related weight gain. The 13 SNPs
most significantly associated with AP-related weight gain came from 9 genes (ADRA2A, ADRB3,
BDNF, DRD2, GNB3, HTR2C, INSIG2, MC4R, and SNAP25). Among these genes, HTR2C was
most consistently associated with antipsychotic-related weight gain. Moderate evidence supporting
the association of ADRA2A, DRD2, GNB3, MC4R, and INSIG2 genes with AP-related weight
gain was also found. The clear result was that AP induced weight gain is polygenic and associated
with a multitude of specific genetic variants, especially in genes coding for AP pharmacodynamic
targets. (3)
Topiramate
Topiramate is an anticonvulsant which blocks alpha-amino-3-hydroxy-5-methylisoxazole-4

propionic (AMPA)/kainate-gated ion sodium channels and is a positive modulator of GABA Rcs.
(7) The potential mechanisms of action include: presynaptic release of glutamate with excessive
glutamate neurotransmission through kainate Rcs lowering the level of excess dopamine and
prolonging stimulation of AMPA/KA Rcs and inhibition of glutamate activity, blunting activity at
Na+ and Ca2+ channels modulating the effects of the GABA-A Rcs. The mechanisms for lowering
body weight and improving metabolic parameters include the following: mitigating appetite
through insulin-sensitizing effects with direct positive modulation of insulin action, leading to
reduced insulin levels and lower blood glucose levels and enhancing the action of lipoprotein lipase
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in the muscle tissue and in the adipose tissue while inhibiting the action of carbonic anhydrase
enzymes who are involved in the process of de novo lipogenesis in the mitochondria and cell
cytosol. (8)
Liang et al., 2016 compared Topiramate with placebo in a meta-analysis from a total of 10
studies, consisting of 453 subjects treated with AP. The results showed Topiramate to be moderate
effective in reducing AP-related weight gain (WMD=-1.82 kg), BMI change (WMD=-1.31 kg/m2)
and fasting glucose increase (SMD=-1.15). It did not find significant evidence of Topiramate
having a regulatory effect in lipid metabolism and no improvements in clinical symptoms using
PANSS were observed. (9)
Zheng et al., 2016 demonstrates in a meta-analysis of 16 RCTs with 934 patients, that topiramate
added to the AP treatment scheme either as an augmentation therapy or coinitiated is far superior
that AP monotherapy. Benefits where seen not only in lowering body weight, BMI, serum
triglycerides, and fasting insulin but also in the general psychopathology symptoms. The mean
topiramate dose was 164.9-70.4 mg/day (range = 50–300, median =139.0 mg/day). This study
showed an advantage in concomitant initiation of topiramate and AP compared to adding
topiramate after weight gain had occurred (-3.5kg vs -1.5 kg). (8)
Kah Kheng Goh et al., 2018 meta-analysis reviewed if Topiramate can mitigate weight gain in
AP-treated patients. It consisted of ten double-blinded randomized placebo-controlled trials and
seven open-label randomized controlled trials and included 905 patients. Topiramate adjunctive
therapy led to significant weight reduction (-3.76 kg) in patients with schizophrenia and also a
significant BMI reduction (1.62 kg/m2) in these patients. The effect of treatment differed with
patient race and ethnicity, but topiramate seemed to significantly improve psychopathology
compared to the control group. Paresthesia being the only side effect that occurred more frequent.
(10).
Metformin
Metformin is an antihyperglycemic biguanide used in the first line treatment of type 2 diabetes
mellitus. By blocking hepatic gluconeogenesis, it helps in keeping blood glucose levels constant
and raising peripheral insulin sensitivity. It has a well-tolerated profile and it is rarely associated
with hypoglycaemia, because it does not increase insulin production. Metformin causes weight loss
in people with type 2 diabetes and prediabetes status. The mechanisms that produce weight loss
are thought to be appetite suppression and stimulation of glucagon-like peptide-1 secretion that
slows gastric emptying. Metformin also enhances the action of insulin in the liver which causes a
reduction in the rate of hepatic glucose production. Metformin has also been shown to have
beneficial effects in schizophrenia on AP-induced hyperprolactinemia and prolactin-related
symptoms. (5) Although several studies had shown it to be effective in managing AP weight gain,
there are still no clear clinical guidelines in use. (8) Metformin may be associated with lowered
levels of folate and serum vitamin B12 which needs constant monitoring in long-term use. (5), (11)
Varuni Asanka de Silva et al., published in 2016 a meta-analysis of 12 studies, that compared
the use of metformin to placebo in patients treated AP. Ten of the studies were of adults and two
of children, with a total of 743 patients. It demonstrates that concomitant treatment with metformin
results in significantly better anthropometric and metabolic parameters. Weight loss was
significantly higher (-3.27 kg) and BMI was significantly more diminished (-1.13 kg/m2) when
administering metformin compared to placebo in patients treated with antipsychotics. Nine of the
studies found that treatment with metformin obtained a more significant reduction in insulin
resistance index IRI (-1.49) than placebo. Metformin also appears to be more effective in
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preventing weight gain in first episode patients treated with AP than in chronic patients who have
already gained some weight. The analysis of subgroups shows that the five trials which included
first episode patients had a mean difference in weight of -5.94 kg, which compared to the trials of
chronic patients of -2.06 kg, was much larger. Pointing towards metabolic changes that occur with
continued use of AP. Patients that are naive to AP treatments have rapid and continuous weight
gain in the first few weeks. At 12 weeks the mean weight gain among this group is 3.8 kg with a
1-point increase in BMI, weight gain that continues the whole duration of AP treatment. Ten of the
studies in the meta-analysis did not find any significant evidence in metformin’s effect in reducing
fasting blood glucose in these patients. (12)
In 2015 Wei Zheng et al., published a meta-analysis of 21 studies about weight gain and
metabolic abnormalities in patients treated with AP. Out of the 21 studies, 11 were published in
English and 10 in Chinese, with a total of 1547 subjects (778 on metformin, 769 on placebo). In
anthropometric variables concomitant treatment with metformin was significantly superior to
placebo in weight gain, BMI and waist circumference. Metformin’s effects on glucose metabolism
were significantly superior to placebo in fasting glucose, fasting insulin, homeostasis model
assessment insulin resistance index and glycosylated haemoglobin A1c. Metformin was also
significantly superior to placebo in its effects on serum lipids such as total cholesterol, TG and
HDL but not in LDL. The metformin group also shown to have significantly lower levels of leptin.
The recommended dose of add-on metformin from this study is 750 mg/day and even lower for
Chinese patients. Ethnic differences between east Asians and Caucasians influence fat distribution.
In the metformin group, side effects such as nausea and/or vomiting were around 14% of patients
and of diarrhoea was 7%, resulting that monitoring for these side effects is mandatory. (13)
Glucagon-like peptide-1 receptor agonist (GLP-1RA)
Glucagon-like peptide-1(GLP-1) is an endogenous peptide, which raises insulin secretion and

decreases glucagon secretion in a manner which is dependent of blood glucose level. Synthesized
in the intestinal mucosa, GLP-1s also have an effect on lowering food intake, by promoting satiety,
through its capacity to delay gastric emptying. GLP-1RAs are well established in their properties
of lowering glucose and weight in both patients that have and do not have diabetes. One of the
considerable benefits of GLP-1RA treatment is a lowering of major adverse cardiovascular risk for
the following: cardiovascular-related mortality, non-fatal myocardial infarction and nonfatal
stroke. Seeing as 35% of excess deaths in patients with schizophrenia are attributable to
cardiovascular disease and diabetes, there has been increasing interest in using GLP-1RAs in
treating these patients. Both to counteract the weight gain associated with AP treatment and for the
metabolic and cardiovascular effects. In addition, several GLP-1RAs are now available as weekly
injections, which eseas administering and adherence to treatment among patients with
schizophrenia. (14)
Siskind D et al., in 2018 published a meta-analysis of 3 studies with a total of 168 patients, to
demonstrate if GLP-1RAs are effective and tolerable in managing weight gain for patients treated
with AP and in particular those treated with Clozapine or Olanzapine. Two of the studies used
exenatide 2 mg s.c., once per week and the other study used liraglutide 1.8 mg s.c. once per day, at
doses that match the standard maximum for use in diabetes. The studies ranged from 12 to 24
weeks with a mean of 16.2 weeks. Patients with add-on treatment of GLP-1RAs lost 3.7 kg more
weight than controls, approximately at the point of 5% body weight for the whole group. The
benefits of GLP-1RA treatment were also in the greater reductions in BMI, visceral fat, fasting
glucose and HbA1c. (14)
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This meta-analysis suggests that GLP-1Ras cotreatment induces a meaningful weight loss in
overweight or obese patients with schizophrenia, who are on AP. The results were greater for
patients on Clozapine and/or Olanzapine, which is in line with the current finding that these 2 AP
disrupt the GLP-1-pathway. The study did not find any evidence that these benefits were modified
by age, sex, psychosis severity or nausea as a side effect. (14)
Non-pharmacological interventions
Weight-management through non-pharmacological interventions must be a priority in the initial

stages of AP treatment. Incorporating dietary and physical activity have shown promise in terms
of avoiding weight gain in patients with schizophrenia.
Guy Faulkner et al., meta-analysis reviewed 23 studies, 5 of which assessed a
cognitive/behavioural intervention and 18 assessed a pharmacological add-on in patient with
schizophrenia. Two cognitive-behavioural trails with a combined 104 patients, achieved significant
treatment effect, with a mean weight change at the conclusion of therapy of -3.38 kg. The other 3
cognitive/behavioural trials, comprising of 129 patients, also showed a significant treatment effect
at end of therapy with a mean weight change of -1.69 kg. (15)
Mario Álvarez-Jiménez et al., researched if non-pharmacological interventions could be used to
manage AP induced weight gain, in a meta-analysis of 10 trials with 482 patients. Six of the studies
investigated strategies using cognitive-behavioural interventions, 3 nutritional counselling and one
a combination of exercise and nutritional interventions. Six of the trials had the objective to reduce
body weight in those that had already gained weight and four studies tried to prevent AP weight
gain. Non-pharmacological interventions obtained statistically significant reduction in mean body
weight (-2.56 kg) compared to usual treatment. Effects on BMI also had significant results with a
mean change in body mass index of -0.91kg/m2. These positive effects are the result of a
combination of techniques which in a flexible manner address individual needs with a focus on
promoting therapeutic alliances. (16)
Non-pharmacological and metformin interventions
Wei Zheng et al., published in January 2019 the first meta-analysis that explored the efficacy
and tolerability of combining metformin and lifestyle intervention (MLC) for AP-induced weight
gain in schizophrenia. The study was divided in three parts: “MLC versus metformin alone”, “MLC
versus lifestyle intervention” and “MLC versus placebo”. MLC group surpassed the metformin-
alone group in mean body weight changes WMD: -1.50 kg and mean BMI change WMD: -1.08
kg/m2. The MLC group also surpassed the lifestyle group in mean body weight changes, WMD: -
3.30 kg, mean BMI changes WMD: -1.45 kg/m2 and waist circumference WMD: -2.10 cm. The
MLC group surpassed the placebo in both changes to body weight WMD: -5.05 kg and mean BMI
changes WMD: -2.85 kg/m2 with MLC showing significantly less weight gain of more than 7%
body mass. These findings demonstrate that the MLC is an effective and safe technique in
managing weight gain compared to either lifestyle intervention, placebo or metformin alone. (5)
Large scale comparative meta-analysis
Davy Vancampfort et al., published in February 2019 one of the largest meta-analysis on the
topics of physical health outcomes of pharmacological and non-pharmacological interventions, in
people with schizophrenia spectrum disorders. The study summarized and compared 27 meta-
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analyses representing 128 trials and 47,231 study participants. A total of 17 different
pharmacological interventions were documented: aripiprazole augmentation, fluoxetine,
metformin, nizatidine, dextroamphetamine, d-fenfluramine, famotidine, metformin in combination
with sibutramine, orlistat, NMDA receptor antagonists including amantadine and memantine,
ranitidine, topiramate, rosiglitazone, fluvoxamine, glucagon-like peptide-1 receptor agonists
(GLP-1 RAs), and switching from olanzapine to quetiapine or aripiprazole.
Six meta-analyses with a total of 78 trials, involving 3,944 patients investigated non-
pharmacological interventions for reducing body weight in schizophrenic patients. The most
effective intervention was individual lifestyle counselling followed by exercise interventions alone.
Dietary interventions alone and psychoeducation that focused on promoting a healthy lifestyle
had a medium effect. With cognitive behavioural therapy focused on promoting a healthy and
group lifestyle counselling having only a small effect on preventing weight gain.
Pharmacological interventions were investigated in 14 meta-analyses containing 82 studies with
4,691 patients. A medium effect size for preventing weight gain was observed for aripiprazole
augmentation, topiramate, d-fenfluramine and metformin and a small significant effect was shown
for NMDA receptor antagonists, GLP-1 RAs and amantadine. No significant weight loss compared
to control was observed for fluoxetine, dextroamphetamine, famotidine, the combination of
metformin with sibutramine, orlistat and rosiglitazone. Also switching from olanzapine to
quetiapine or aripiprazole fell short of statistical significance.
Combined interventions were explored in one meta-analysis with 122 patients and was
demonstrated to have a small significant effect on body weight.
In summary, Davy Vancampfort et al., demonstrates that the most effective interventions for
body weight control in patients under AP treatment are: individual lifestyle counselling and
exercise interventions followed by psychoeducation, aripiprazole augmentation, topiramate, di-
fenfluramine and metformin add-on treatments. (17)
Chuanjun Zhuo et al., 2018 published a meta-analysis of 27 studies, with 1,349 subjects
reviewing effective add-on treatments in controlling AP-induced weight gain. Efficacy results on
adjunctive treatments were reported: with Topiramate in 4 studies, Metformin in 13 studies,
Reboxetine in 3 studies, Ranitidine in 2 studies, and Sibutramine in 4 studies. Topiramate showed
the lowest mean difference in body weight with -3.07 kg, followed by Sibutramine with -2.97 kg,
Metformin at -2.50 kg and Reboxetine with MD = -2.25 kg. All showed weight reductions
comparing to placebo, except for Ranitidine.
Excluding studies with less than 12 months follow-up the authors could show which add-on
treatments were consistently significant with a reduction in body weight. With more than 12
months of treatment metformin, sibutramine and topiramate maintained their efficiency with -2.54
kg, -2.98 kg and -2.95 kg mean body weight difference.
Although useful in managing weight Sibutramine should not be used to treat AP-induced weight
gain. The Sibutramine Cardiovascular Outcomes Trial confirmed that subjects with pre-existing
cardiovascular disease had a considerable increased risk for non-fatal myocardial infarction and
non-fatal stroke on long-term treatment. (7)
Conclusions
While obesity is clearly linked to physical comorbidity, it’s relation to mental health has been
less explored. Knowledge gaps still exist in the association between obesity and various psychiatric
conditions like schizophrenia (18, 19, 20). Weight gain is also associated with low quality of life,
social stigma, poor treatment adherence, and high health-care costs. While both conventional and
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newer generation AP are associated with weight gain, the existing evidence for pharmacological
and non-pharmacological interventions that can be used to prevent this is still limited. Weight gain
should be discussed in detail and strictly managed for all patients prescribed AP, especially for
olanzapine.
Topiramate, and Metformin are two options that can be used safely in an adjunctive treatment.
They are both well tolerated over a short-term period and are effective add-on treatments in
controlling antipsychotic-induced weight gain.
The research field should move to large-scale investigations of combination regimes using both
antipsychotic switching and adjunctive treatments alongside lifestyle interventions as well as
preventive interventions.
REFERENCES
1. Tek C et al., (2016). Antipsychotic-induced weight gain in first-episode psychosis patients: a meta-analysis
of differential effects of antipsychotic medications. Early Interv Psychiatry. 10(3): pp. 193-202.
2. Rajan T et al., (2017). Psychiatric disorders and obesity: a review of association studies. J Postgrad Med
63(3): p. 182
3. Zhang JP et al., (2016). Pharmacogenetic associations of antipsychotic drug-related weight gain: a systematic
review and meta-analysis. Schizophr Bull. 42(6): pp. 1418-1437.
4. Bak M, et al., (2014). Almost all antipsychotics result in weight gain: A meta-analysis. PLoS ONE 9(4):
e941129.
5. Zheng W et al., (2019). Combination of metformin and lifestyle intervention for antipsychotic-related weight
gain: a meta-analysis of randomized controlled trials. Pharmacopsychiatry. 52(1): pp. 24-31.
6. Spertus J. et al., (2018). Risk of weight gain for specific antipsychotic drugs: a meta-analysis. NPJ Schizophr.
4(1): p. 12.
7. Zhuo C. et al., (2018). Topiramate and Metformin Are Effective Add-On Treatments in Controlling
Antipsychotic-Induced Weight Gain: A Systematic Review and Network Meta-Analysis. Frontiers in
Pharmacology, 9: 1393.
8. Zheng W. et al., (2016). Efficacy and safety of adjunctive topiramate for schizophrenia: a meta-analysis of
randomized controlled trials. Acta Psychiatr Scand.;134(5): pp. 385-398.
9. Liang H. et al., (2016). Effects of Topiramate for atypical antipsychotic-induced body weight gain and
metabolic adversities: a systematic review and meta-analysis. Zhonghua Yi Xue Za Zhi. 96: pp. 216-23.
10. Goh KK. et al., (2018) Topiramate mitigates weight gain in antipsychotic‐treated patients with schizophrenia:
meta‐analysis of randomised controlled trials. Int J Psychiatry Clin Pract. 23(1): pp. 14-32.
11. Jarskog LF. et al., (2013) Metformin for weight loss and metabolic control in overweight outpatients with
schizophrenia and schizoaffective disorder. The American Journal of Psychiatry. 170: pp. 1032-1040.
12. de Silva Va. et al., (2016). Metformin in prevention and treatment of antipsychotic induced weight gain: a
systematic review and meta-analysis. BMC Psychiatry. 16(1): p. 341.
13. Zheng W. et al., (2015). Metformin for weight gain and metabolic abnormalities associated with antipsychotic
treatment: meta-analysis of randomized placebo-controlled trials. J Clin Psychopharmacol. 35(5): pp. 499-
509.
14. Siskind D. et al., (2018). Glucagon‐like peptide‐1 receptor‐agonists for antipsychotic‐associated cardio‐
metabolic risk factors: a systematic review and individual participant data meta‐analysis. Diabetes, Obesity
and Metabolism, 21(2), pp. 293-302.
15. Faulkner G et al., (2007). Interventions to reduce weight gain in schizophrenia Schizophr Bull, 33 (3) pp. 654-
656
16. M. Álvarez-Jiménez et al., (2008). Non-pharmacological management of antipsychotic-induced weight gain:
systematic review and meta-analysis of randomised controlled trials. Br J Psychiatry, 193 pp. 101-107
17. Vancampfort D et al., (2019). The impact of pharmacological and non-pharmacological interventions to
improve physical health outcomes in people with schizophrenia: a meta-review of meta-analyses of
randomized controlled trials. World Psychiatry, 18(1), pp. 53-66.
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54, p. 66.
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Mindfulness: A Psychotherapeutic Method of Acceptance and

Centering of the Mental Framework
DOBRI Mirona Letitia1, VOINEA Alina-Ioana1, RĂDULESCU Ionuț-Dragoș1,

1“Socola” Institute of Psychiatry Iași (ROMANIA)
2“Dunărea de Jos” University of Medicine and Pharmacy Galați (ROMANIA)
Emails: craciunpetronela@yahoo.com, anamburlea@yahoo.com, mirona.dobri@gmail.com,
alina_ioana92@yahoo.com, ionut1989dragos@yahoo.com
Abstract
Mindfulness as a term comes from Buddhist traditions, translating as awareness, concentration

or remembrance. Western neuroscientists define mindfulness practices as a combination of
emotional and attentional training regimes that help cultivate physical and psychological well-
being and improve emotional regulation while noting neurobiological changes in the brain.
The formal introduction of oriental ways of thinking into western philosophy, psychology and
medicine happened decades ago, generating a large spectrum of discussions and scientific works
concerning the therapeutic applications of the mindfulness practice. Basing our presentation on a
thorough study of scientific papers, we propose a synthesis of the theoretical aspects related to
mindfulness and a new perspective regarding its applications in the clinical psychiatric care.
The modern occidental approaches of the practice are adapted into methods used in cognitive
therapy based on mindfulness. The benefits of formal practice proven from the neurological
perspective are the result of a less reactive autonomic nervous system. Regulation of attention,
body awareness, regulation of emotions, increased capacity of adaptation is just a few of the
mechanisms involved. Therefore, it is integrated into western psychotherapy as an adjunctive or
alternative method of treatment for several psychiatric disorders among which are depression,
anxiety, substance use, smoking cessation, insomnia.
In conclusion, mindfulness has shown to have great promise in clinical application, and the hope
is to be used in the future with the purpose of improving mental and physical wellbeing and quality
of life.
Keywords: mindfulness, adjunctive therapy, mood disorders, anxiety, awareness, neural pathways
Mindfulness: More Than a Concept
Mindfulness has become a term widely used in today’s world, a trend in both in academic and
non-academic contexts. Defining mindfulness is hard, as the word itself comes from Pali, the
language of Buddhist psychology from two and a half millennia ago, which makes mindfulness a
concept that originates from the Orient of those times. [1] Jon Kabat-Zinn, the one who integrated
mindfulness into western psychology and medicine defines it as awareness cultivated by sustained
attention to the present moment without judgement. [2] Alternate authors define it as a practice of
learning to focus attention on moment-by moment experience with an attitude of curiosity,
openness, and acceptance. The word “Sati” which translates into mindfulness means awareness,
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attention and remembrance. Mindfulness is the opposite of functioning on autopilot or

daydreaming but being aware of what happens in the present moment. It also includes
remembrance of returning attention and awareness to the present experience. Another crucial term
involved in mindfulness is acceptance of the present experience exactly as it is without resisting.
It does not refer to acceptance in the general terms, but acceptance of that which cannot be
changed. [1] Accepting pain is one of the most utilized angles which many mindfulness-based
medical approaches target.
It is a lot more than a theoretical concept, as it also describes concepts of a practical nature, such
as various practices of meditation and psychological processes or mechanisms of action on the
mind and on the brain. The two alternative methods for integrating mindfulness into our lives are
the formal way, by practicing meditation, taking the time to practice the techniques in a constrained
and controlled environment and the informal way, by trying to apply them in an unplanned way in
every aspect of our lives. Meditation in itself has various levels of practice. A more deep, pure form
seen in ancient Buddhism of Southeast Asia or in Tibetan yogis and a wide approach taken out of
spiritual or religious context and modified, secularized and adapted to the needs of the western
civilization, both in medical context and as a way of life. [3] It is this modality which we will be
referring to across this text.
Mindfulness includes a series of techniques that can be applied both in the formal and informal
practice. The most widely used is harnessing attention to the present moment by concentrating on
breathing. Our mind wanders relentlessly from one subject to the next, and the breathing is used as
an anchor for it, as a neutral point for the mind to return to every time it diverts from the present.
The guideline encourages acceptance of the thoughts as they pass by and returning attention to
respiration. Another way to anchor the mind is attention to surrounding sounds, without labelling
them or judging them. Body scanning is a technique meant to encourage acceptance of sensations
by consecutively scanning every part of the body, as by being slower and steadier than the mind, it
is a great observation point for it and its emotions. Therefore, formal meditation practices are not
in themselves a purpose in life but are a tool for easing living life with discomfort. [1, 3]
There are a few common misconceptions about what mindfulness is or is not. Even though it
has been practiced by Buddhist monks for thousands of years it is not a religion, but an exercise of
increasing awareness to the moment by moment experience, exercise which is the foundation of
various psychotherapeutic approaches. It is not meant as an attempt at relaxation, but rather as a
way of being less surprised at the emotions within. It is not a way to empty the mind of all thought
but to develop a different relationship with the thoughts and emotions through a better
understanding of how the mind works. It is not a way to transcend the mundane, but rather to revel
in the small banalities of life. [4]
How Mindfulness Shapes the Neurobiology of Our Brains
Mindfulness and meditative practices are considered to be the appanage of Oriental philosophy
and psychology, but their informal introduction into the western culture happened centuries ago,
with transcendentalists like Henry David Thoreau and Ralph Waldo Emerson, and found their way
into academic circles around the beginning of the twentieth century. They took a more serious hold
mere decades ago, in the seventies, when teachers from the East started arriving in Europe and
America and westerners started travelling to India and Tibet to study with local monks. This made
way for a slow and gradually increasing wave of research studies on the subject with the purpose
of analysing the benefits and claims within the boundaries of science. In the recent years the count
for mindfulness and meditation studies has risen to over 6000, with 2014 claiming 925 studies, in
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2015 there were 1098 and in 2016 there were 1113 such papers. [3] There are still some conceptual
and methodological issues with such publications in terms of the difficulty of standardization
because of the many different varieties of practices, the different level of experience of the
meditator groups and assessment of the results though imaging or other methods. [5] We have
made it our aim to study and analyse the general directions and conclusions taken from that research
in the hope to understand the neurobiological mechanisms involved and consider the applications
they can have in our clinical practice.
A scientific concept crucially involved in the neurobiology of mindfulness is that of
neuroplasticity. In order to see a change in the external manifestation or behaviour of humans, a
change at the level of the brain needs to happen. When a certain behaviour is repeated multiple
times, for instance the returning of attention to the present moment within the practice of
mindfulness, the wave of brain activity changes gradually, and this gradually implemented brain
pattern transposes into behavioural patterns both inside and outside the mindfulness practices. [1]
Based on this concept, scientists have tried to identify specific neural networks that are activated
in the frame of these practices and shaped through neuroplasticity. These vary greatly, depending
on multiple factors including the type of practice being studied and the experience of the people
being part of the study. One of these networks was studied in 2001 by Debra Gusnard and Marcus
Reichle and is called the default mode network (DMN). DMN is active when the mind is at rest
and completes elemental tasks of information integration necessary for baseline functioning and
has the role of giving and maintaining the sense of self and identity of a person at rest. It is the one
which generates spontaneous thoughts and is active when the mind wanders during mindfulness
practices. Its deactivation results in a state of focused attention with minimal self-reference
thoughts. Its importance was observed in many psychiatric and neurological diseases, as
Alzheimer’s Dementia and Autism Spectrum Disorders. Numerous studies used the functional
MRI imaging technique to compare the activity of the DMN in experienced meditation
practitioners versus control groups comprised of non-meditators. It was observed that after various
distraction stimuli, experienced meditators managed to deactivate the DMN, had diminished chains
of associations in the mind and returned promptly to anchors like the breathing, compared to the
control group. [6,7]
Another region activated during mindfulness practices is the anterior insula. This region has a
crucial role in interception, in the perception of visceral sensations and controlling autonomic
responses like heart rate and breathing, contributing therefore at defining our perception of the
inner self. It has been observed that during mindfulness practices, this region of the brain has
increased activity, attributed to the fact that the practitioner develops an increased attention to
passing sensations in the body. The insula is also implicated in affectivity, empathy and relationship
to pain. Studies using fMRI on subjects who have seen distressing materials of people suffering
have shown that circuits that are part of the insula light up in response, indicating suffering of the
viewer reflecting the distressing material. Distressing circuits of the insula have multiple
connections to another region of the brain, the amygdala. [8, 9]
The amygdala is implicated in the processing of intense emotions of both positive and negative
nature and mediates the reaction to stress. Studies have highlighted the finding that beginners in
meditation have a higher amygdala activation in response to stressful stimuli and painful images
compared to experienced practitioners. [10]
Studies have highlighted various changes noticed in the brain structure as a result of a long-term
mindfulness practice. By using neuroimaging techniques, it has been found that brain grey matter
increases in size in multiple regions of the brain activated during meditation. Experienced
practitioners have shown an increase in grey matter thickness at the level of anterior insula and
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sensitive cortex as a result of increased attention and control of sensorial internal and external
stimuli. As the thickness of insular grey matter decreases with age, mindfulness could help slow
down the process of thinning of this region that takes place normally when a person is aging. [11]
Examining grey matter structures of experienced meditators has yielded multiple different
results, in part because of the multitude of different practices, subjects and study designs, but a
number of regions have been a constant across all these results: the right anterior insula, the inferior
temporal gyrus and the hippocampus. [12] The latter constitutes the only part of the brain that can
generate new neurons as a person ages, but this process is often impeded by the secretion of cortisol,
the stress hormone. It has been observed that in experienced meditators these is an increased
thickness of this region compared to non-meditators, suggesting that meditation has the potential
to control the negative changes of cortisol. [13] Trying to see if similar changes start to take place
in people who have not practiced mindfulness for long, scientists have analysed subjects
participating in the Mindfulness-Based Stress Reduction (MBSR) Program. Four brain regions
have shown modifications after the 8 weeks required to complete the program: the hippocampus,
the posterior cingulate cortex, the temporo-parietal junction and a part of cerebellum. The insular
grey matter was also increased, but not in a statistically significant way. The hippocampus is
involved in memory and learning, the posterior cingulate gyrus is part of the DMN, and even
though DMN activity decreases during meditation states, it is concluded that an increase in the
density of this gyrus is based upon the complex relationship between structure and function at the
level of the brain. The temporo-parietal junction plays a central part in empathy, compassion and
the sense of self, the increase of this region meaning a better awareness of the body. A meaningful
addition is the finding of decreased amygdala activity and a diminished amygdala density,
correlating with a better physiological response to stressful stimuli and a decreased cortisol activity.
[1, 14]
The Mindfulness Approach in Psychotherapy
Although mindfulness meditation was never intended to be used in a medical context, it has
shown great promise due to its numerous benefits both from an empirical standpoint and hinted at
or proved scientifically. There are four important therapeutic approaches based on mindfulness, as
follows: mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy
(MBCT), dialectic behavioural therapy and acceptance and commitment therapy. These forms of
therapy each are intended to target different psychological and psychiatric problems.
Introducing mindfulness into the frame of psychotherapeutic practice can be a challenge,
especially when the patient is unsure, vulnerable and sceptical towards treatment. A good approach
can be proposing an experiment, only when both the therapist and patient maintain an open mind
and are open to the trial of different practices and a good therapeutic relationship is present. When
proposing a technique, one must take into account, among others, patient preferences, personality,
chief complaint and other pathologies. Mindfulness focused on breathing might not be appropriate
to patients suffering from anxiety or respiratory problems such as COPD or asthma or even OCD
patients, as they might be too focused on controlling rhythm of breathing. Attention to sounds
might trigger fear responses in patients suffering from PTSD. Meditations focusing on body
sensations might be adequate for OCD patients, as they can constitute a distraction from obsessive
thoughts, but prove problematic in patients with dissociative disorders, as they can exacerbate
symptoms or produce confusion.
In depressive syndromes, mindfulness toward disposition can protect against depression as it
regulates affect and promotes acceptance. Formal mindfulness techniques can stimulate positive
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feelings and reduce rumination. MBCT and acceptance and commitment therapy are two
approaches often used with these patients. These approaches help patients confront the pain they
are feeling and promote a change in their relationship to it. Therapists often deconstruct depressive
syndromes into its components, emotions, thought and physical symptoms, in order to use different
techniques to target each of these aspects. Medication is used in conjunction with psychotherapy
in severe forms to decrease symptoms in order for the patient to be able mentally and physically to
engage in the mindfulness practices. [15]
Anxiety sufferers also benefit from programs such as MBSR, MBCT and acceptance and
commitment therapies as they teach patients to relate differently to their interior experiences. Fear
and anxiety are normal adaptive responses that appear when we confront a menacing or perilous
situation. They activate the fight or flight response which implies autonomic nervous system
involvement like diaphoresis, increased heart rate, increased rate of breathing and can be
accompanied by subjective experiences like sense of impending death. Applying mindfulness-
based therapies help these patients monitor the symptoms in a gently and compassionate manner,
increase their level of awareness and understanding of their anxious response and identify and
combat their anxiety-provoking thoughts. Studies show that mindfulness-based therapies prove
most effective and improve quality of life in patients suffering from social anxiety, generalized
anxiety disorder and obsessive-compulsive disorder. [16]
Insomnia is a worldwide issue often understated and has a variety of causes, among which
caffeine consumption, evening naps, sleeping beside someone who snores, obstructive sleep apnea,
polypharmacy and others. The real problem instead is that relentlessly trying to sleep and incessant
thinking about not being able to sleep stresses the body and induces the fight-or-flight response
that keeps us awake. Therefore, a vicious circle is created that amplifies the problem. Mindfulness-
based interventions have the role of changing thinking patterns when sleep is attempted. A few of
the new patterns include being more aware that less sleep often wakes you up feeling more
energized, which can reduce the feeling of urgency to fall asleep, laying on the pillow is often a
very restful activity regardless of sleep. [17]
Mindfulness-based interventions have proven helpful in patients suffering from various
addictions, including substance use, smoking or excessive eating by increasing awareness of the
negative effects these activities have on the body as they happen, identifying the external triggers
that lead to executing the activity and deconstructing the internal causes for being more susceptible
to those triggers. By applying mindfulness techniques, the patient can adopt an attitude of
acceptance of the emotions and sensations that prompt the consumption and develop non-reactivity
towards them. [18, 19, 20, 21]
Conclusions
Body and mind are two entities that are meant to work in synergy and synchronizing them is the
key to creating the optimal human experience. Practicing mindfulness helps one harness a great
number of qualities of the mind otherwise difficult to access and owning one’s own internal and
external experiences. The various therapeutic approaches help patients get closer to that much
desired level of functioning. Interest in the subject of mindfulness and how it can be of use in a
therapeutic context is rising day by day based on the ever-increasing number of research papers
meant to answer questions never asked before. The research approaches, study designs and imaging
methods improve alongside the evolution of technology and previous experience. We have
promising results that we can draw from in our eternal quest of improving patient care and hope
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the future will bring a better understanding of an element that always constituted a mystery and a
challenge, the human mind and brain.
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8. Lutz A., Greischar L.L., Perlman D.M., Davidson R.J. (2009). Regulation of the neural circuitry of emotion
by compassion meditation: Effects of meditative expertise. PLoS ONE, 3(3), e1987.
9. Lutz A., Greischar L.L., Perlman D.M., Davidson R.J. (2004). BOLD signal in insula is differently related to
cardiac function during compassion meditation in experts vs. novices. NeuroImage, 47(3), pp. 1038-1046.
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Eric L (20120. “Effects of mindful-attention and compassion meditation training on amygdala response to
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Psiho-Oncologia. Case Presentation
PÂSLARU Ana Maria1, FĂTU Ana Maria1, SÂRBU Fabiola1,

NECHIFOR Alexandru2, REBEGEA Laura3, CIUBARĂ Anamaria4
1 PhD student at University “Dunarea de Jos”, Galați, (ROMANIA)
2 PhD student at University of Medicine and Pharmacy, “Carol Davila”, București, (ROMANIA)
3 PhD, Department of Oncology, Faculty of Medicine and Pharmacy, “Dunărea de Jos University”, Galați, (ROMANIA)
4 PhD, Department of Psychiatry, Faculty of Medicine and Pharmacy, “Dunarea de Jos University”, Galați, (ROMANIA)
Emails: nafatu09@gmail.com
Abstract
Increased survival of oncology patients brings to attention new aspects of adverse effects due to
antineoplastic treatment. Psychiatric disorders, cardiovascular disorders as well as the progressive
incidence of multiple primary neoplasia’s are some of the most common side effects.
Aim
Care of the oncology patient undergoes an important period of change, from the management
of tumour disease to the multidisciplinary approach, centered on improving the quality of life.
Method
We present the case of a 75-year-old patient, whose personal pathological history reveals the
presence of a diagnosis of left testicular seminoma, in 1978, for which he received radiochemical
therapy. An oncological patient under long-term medical supervision for several decades is
diagnosed in November 2017 with urothelial carcinoma, infiltrative, invasive in his own muscle
patch, pT2NxMx. Approximately 40 years later, the second neoplastic site, the malignant bladder
tumour, appears. Facing this diagnosis, the patient becomes anxious, anticipates catastrophic
consequences, isolates himself. The family and friends support are essential in these moments, the
patient tries cognitive-behavioural psychotherapy, as well as various relaxation techniques, which
have positive results for the patient attitude towards the disease. He admits, in order to complete
staging, to follow the recommendations of the oncologist, perform proton emission tomography,
which detects the presence of two lesions on the right lung. In January 2018, the surgical
intervention is done by straight thoracotomy, atypical upper lobe resection and inferior lobectomy
is performed. The histopathological and immunohistochemical results describe the presence of the
third primary adenocarcinoma neoplasia. The initial emotional reaction is one of anger, denial,
followed by demoralization, easy crying, sadness. The patient is examined by the psychiatrist, thus
receiving the diagnosis of a severe depressive episode without psychotic symptoms. He follows an
anxiolytic, antidepressant, sedative treatment but continues also the cognitive-behavioural therapy.
The patient shows good compliance with psychopharmacological treatment and accepts
adjuvant chemotherapy courses, which are well tolerated. Throughout the antineoplastic therapy,
there was a close collaboration between the psychiatrist and the oncologist, to avoid drug
interactions that could have led to interruption of the treatment. Under the oncology supervision,
the patient receives another bad news, in September 2018, the fourth neoplastic localization, the
prostatic adenocarcinoma pT2bN0M0, is discovered. In this case, in the presence of the
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combination of synchronous and methacrone tumours, the patient’s psyche is deeply affected,
continuing the psychopharmacological treatment. Conclusions: Psychiatric disorders are common
among oncological patients, and they may suffer serious impairments in quality of life and
treatment compliance, psycho-oncological collaboration being indispensable for the success of
antineoplastic treatment.
Keywords: Multiple primary neoplasia, depression, oncology patient, treatment
Introduction
Within the framework of recent statistics, therapeutic advances have improved the survival of
oncology patients. [1] The World Health Organization estimates an increase in the incidence of
neoplastic diseases in the coming years, the number of deaths due to oncological diseases will reach
Romania in 2040 to 60,000, so cancer remains one of the diseases with a significant psychosocial
impact [2]
Care of the oncology patient goes through an important period of change, from the management
of tumour disease to the approach centered on improving its quality of life. [3]
Psycho-oncology, as part of interdisciplinary medicine, involves communication and
cooperation between specialists in different medical and non-medical fields, proposing to promote
patient accountability and increase its participation in decision-making, of the compliance with the
therapeutic program and implicitly increasing its satisfaction with regard to treatment [3].
The prevalence of psychological-psychiatric disorders in cancer patients is estimated in some
47% of studies (Derek Doyle 2001), of which anxiety and depression 68%, 13% major depression,
8% delirium [4, 5]. Identifying depression in oncology patients is difficult. Depression can easily
be overlooked because cancer symptoms and its treatment resemble the neurovegetative symptoms
of depression, such as fatigue, loss of appetite and sleep disturbance [6].
A number of researchers have studied the emotional reactions of people with cancer. Greer and
Watson [6] observed and described five characteristic patient responses to cancer diagnosis.
Survivors of a cancer can develop certain psychiatric disorders during their lifetime or at the
time of recurrence diagnosis, requiring psychotherapy and specialized treatment [7, 9]. The
emotional response of the person with cancer is determined by three factors: the point of view of
the diagnosis, the perception of disease control, and the vision of the prognosis [8].
Case presentation
We present the case of a 75-year-old urban patient with a performance index (IP) = 1,
insignificant heredocolateral (AHC) antecedents, of particular importance are the personal
pathological antecedents that draw attention to the existence in 1978 of a diagnosis of the left
testicular seminoma , for which the patient underwent polychemotherapy therapy and total dose
(DT) = 40 Gray radiotherapy. After the treatment, the patient was declared cured but remained
under oncology for 5 years, during no recurrence was detected. Concerned about his state of health,
the patient continues oncology monitoring for a long time, being considered free of illness for
several decades.
In the 2017 oncology re-evaluation, the CT scan performed for the thorax, abdomen and contrast
pelvis (SC) reveals the presence of a 5mm long, right-lined basal lymph node. Parietal bladder
changes with possible tumour substrate (Fig. 1a) Prostate with dimensions 30/36 mm, median lobar
hypertrophy and bladder footprint (Fig. 1.b) No free fluid in the peritoneal cavity. Prostate specific
antigen (PSA) value = 4.38 ng/ml.
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Fig. 1.a. CT image axial plan, Parietal bladder Fig. 1.b. CT image sagittal plan, Prostatic
changes hypertrophy
The patient is referred to the urology service where he receives a recommendation to perform a
prostatic biopsy and a cystoscopy. In November 2017, cystoscopy is performed with transurethral
resection of a ¾ cm formation, centered on the right ureteral opening, with favourable later
evolution. The result of the histopathological (HP) examination, high-invasive urothelial
carcinoma, invasive in the bladder-like muscle. There is no lymphovascular or perineural invasion.
Staging of tumour metastasis (TNM) -pT2NxMx.
Facing a new oncology diagnosis, the patient anticipates catastrophic consequences, becomes
anxious, isolates himself, refuses any medical help. Family and friends are actively involved in
improving mental health, using individual and group cognitive behavioural therapies in order to
understand the situation they are crossing, to regain communication with others, but also with the
hope that they will be managed to defeat cancer this time. The combination of psychotherapy and
relaxation techniques to which the patient is appealing changes his attitude towards the disease and
accepts that, in order to complete the staging, he should follow the recommendations of the
oncologist. He performs a CT scan (PET/CT) Whole Body, that detects the presence of an active
metabolic knot (SUV = 5.03), located in the posterior segment of the upper right lobe, with
dimensions of 13/12 mm. Metabolically active pseudo nodal lesion (SUV = 2.42), located in the
postero-basal segment of the right lower lobe, with dimensions of 36/21 mm. Pulmonary CT and
PET lesions comparable to an ’in situ’ bronchial-alveolar invasive mucosal carcinoma.
Fig. 1. PET/CT image active metabolic node active upper right lobe (left) and metabolically active pseudo-nodular
lesion inferior lobe right (right)
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The consultation practised in the thoracic surgery service recommends the surgical resection of
the two metabolically active formations, following spirometry and fibro-bronchoscopy. In January
2018, a right thoracotomy was surgically performed, and FOWLER segment was invisible, with
an invasion in the dorsal segment of the upper right lobe, a node approximately 2 cm excised by
atypical lung resection. In the right inferior lobe, there is an imprecisely defined tumour of
approximately 3.5-4 cm, for which inferior lobectomy is performed. The histopathological and
immunohistochemical result (IHC) describes the presence of the third primary neoplasia primitive
pulmonary adenocarcinoma. Staging pT4N0. The genetic status that identifies the epidermal
growth factor receptor (EGFR) mutant exon 20 is evaluated [10]. Emotional response to the
diagnosis is firstly emotional immobility, followed by denial, seeking answers. Later, anger,
demoralization, easy crying, sad, feel that all physical suffering and endeavour so far have been in
vain, its vision of prognosis is bleak. He goes to the psychiatrist, receives the diagnosis of a severe
depressive episode without psychotic symptoms. Following anxiolytic, antidepressant, sedative
treatment, the psychotherapy sessions continue to be combined with relaxation techniques. The
entire therapeutic arsenal helps the patient change his perception of prognosis and accepts
chemotherapy, performs adjuvant chemotherapy, 4 series with good adherence to treatment. It
respects the recommendations of the oncologist, examines the MRI (RM), that describes the
presence of diffuse cortical atrophy and fronto-parietal subcortical lesions with vasculo-
degenerative aspect.
The oncological re-evaluation in August 2018, biological constants are within normal limits
with PSA exception = 6.54 ng/ml, thoracic CT examination, abdomen, native pelvis and contrast
substance describe the pleuro-pulmonary aspect of the stationary aspect. Liver with normal size,
homogeneous structure. Modified degenerative-arthrosic changes in the thoracic and lumbar spine.
No bone damage suggestive of secondary determinations. RM pelvis 3 Tesla concludes a
minimal deformation of the bladder in the lateral and posterior walls in the ½ right, with its thinning
and parietal thickening in rest, without tumour masses. Prostate hypertrophy of adenomatous
appearance of the central prostate and with the presence of an area raising the suspicion of an
adenocarcinoma in the peripheral prosthesis of the right lobe.
The patient is referred to the urology service, where he will perform ecogydate multiple prostate
biopsy. The result of HP and IHC prostatic adenocarcinoma acinar, Gleason score 6 (3+3)
highlights the presence of the fourth primary malignancy, malignant tumour (TM) of the prostate.
Staging pT2bN0M0. The therapeutic decision is difficult for this patient, radical cystectomy
with neoplastic might be an alternative of treatment with a curative visa, involving two of the four
cancers [11, 12, 13]. Taking into account the profoundly affected psychic, the age, the low degree
of aggressiveness of the prostate tumour, but also the personal pathological antecedents, the active
surveillance with 3-month PSA dosing is decided and pelvic MR. Under these circumstances, in
the presence of synchronous and metacrone tumours, the patient remains under
psychopharmacological treatment.
Conclusions
Oncological surveillance is an extremely important stage in the management of tumour disease,

with improved antineoplastic therapies and increasing survival of these patients, there are new
problems emerging from the treatment of this disease [14, 15, 16]. Tumour recurrences or the
appearance of another cancer during the life of the oncological patient require long-term
surveillance [17, 18]. Multiple primary neoplasms are a reality in oncology.
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The multidisciplinary approach of the oncology patient is paramount, interdisciplinary

collaboration being indispensable for the success of antineopathic treatment.
Before the cancer diagnosis, the patient reacts by trying to adapt to the idea of oncological
disease, but also to accept the treatment that is sometimes difficult to endure. Emotional symptoms
can be missed or even viewed with distrust, minimized, being seen by family and friends as side
effects of treatment or as a consequence of disease progression.
Patients with such neuropsychiatric disorders require entourage support as well as specialized
help. Psychiatric disorders are common in these patients and without psychiatric support they may
suffer serious issues regarding the quality of life and compliance to treatment.
REFERENCES
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cancer survivors-a systematic review of quantitative studies: Fear of recurrence and disease progression in
long-term cancer survivors. Psycho-Oncol. 2013; 22(1): pp. 1-11.
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Româna, vol LXII, nr 3, 2005.
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6. Greer S., Watson M., Mental adjustment to cancer: its measurement and prognostic importance. J. Cancer
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review of quantitative studies. J Cancer Surv. 2013; 7(3): pp. 300-322.
8. Clarke D.M., Psychological adaptation, demoralization and depression in people with cancer. Chichester:
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9. IONESCU G., Psihoterapia, Bucureşti, Editura Univers Enciclopedic, 1990.
10. Shepherd F.A., Rodrigues Pereira J., Ciuleanu T. et al. Erlotinib in previously treated non-small-cell lung
cancer National Cancer Institute of Canada Clinical Trials Group. N Engl J Med 2005; 353: pp. 123-132.
11. Thompson I.M. et al. Assessing prostate cancer risk: results from the Prostate Cancer Prevention Trial. J Natl
Cancer Inst 2006; 98: pp. 529-534.
12. Klotz L, Active surveillance with selective delayed intervention: using natural history to guide treatment in
good risk prostate cancer. J Urol 2004; 172(5 Pt 2): pp. S48-S51.
13. Autier et al., Cancer survival statistics should be viewed with caution. Lancet Oncol 2007; 8: pp. 1050-1052.
54, pp. 66.
16. Lupu, V. V., Ignat, A. N. C. U. T. A., Paduraru, G. A. B. R. I. E. L. A., Ciubara, A., Ioniuc, I., Ciubara, A.
B., ... & Burlea, M. (2016). The study of effects regarding ingestion of corrosive substances in children. Rev
Chim, 67, pp. 2501-3.
17. Epstein J.I., Amen M.D., Reuter U.R., et al., The World Health Organization International Society of Urologic
Pathology (ISUP) consensus classification of urothelial (transitional cell) lesions, neoplasms of the urinary
bladder. Am J Surg Pathol 1998; 22: pp. 1435-1448.
18. Simard S., Savard J., Fear of Cancer Recurrence Inventory: development and initial validation of a
multidimensional measure of fear of cancer recurrence. Support Care Cancer. 2009; 17(3): pp. 241-251.
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Burnout Syndrome at the Anaesthesia & Intensive Care and

Surgical Unit’s medical personnel within Emergency Clinical
Hospital of Galati – Original Study
MANOLE Corina1*, CIUBARĂ Anamaria, FIRESCU Dorel, ŞERBAN Cristina,

ŢOCU George
1 Ph.D, “Dunarea de Jos” University, Galati, (ROMANIA)
* Corresponding author: corinampalivan@gmail.com
Abstract
Scope: identification of burnout syndrome at the mentioned medical personnel and

implementation of some measures to reduce its effects.
The study had been prospective, performed in the period between February and April 2019 on
a sample of 180 subjects comprising AIC (Anaesthesia & Intensive Care) physicians, nurse
anaesthetists, nurses and healthcare assistants from ICU and from the surgical unit within
Emergency Clinical Hospital of Galati. MBI (Maslach Burnout Inventory) survey, validated in
Romanian, was self-administered in order to collect the data. 141 subjects responded out of 180,
representing 78.33%. Out of these, a number of 99 subjects present burnout syndrome, respectively
a percentage of 70.21%. As reported to the three components of the survey, 73.76% of the subject’s
present emotional exhaustion at medium and high levels, 46.81% present depersonalization and
62.42% present personal accomplishments’ reduction. According to the professional categories,
the highest stress level is registered at the ICU healthcare assistants with 100% burnout, followed
by AIC physicians with 80%, nurses and healthcare assistants from the Surgical Unit 64.45%, ICU
nurses 61.29%, the “lowest” level being 55.56% for the nurses from Anaesthesia Department. It
must be noted the severe burnout level according to the profession: as per the emotional exhaustion
level, AIC physicians are affected in a percentage of 33.33%, ICU nurses 19.5%, nurse
anaesthetists 16.67%, nurses from the Surgical Unit 16.36% and ICU healthcare assistants 13.64%.
In conclusion, this study shows that the most affected categories are the ICU healthcare
assistants and AIC physicians, the physicians having the greatest level of emotional exhaustion,
and the healthcare assistants the greatest level of personal accomplishment’s reduction.
Keywords: Burnout, AIC, Surgical Unit, Emotional Exhaustion, Personal Accomplishment Reduction
1. Introduction
Burnout syndrome has become a present-day reality, affecting various forms of social-
professional categories and especially, professionals from medical area. The dictionary definition
of the word: burn + out is total combustion, “psychic carbonization”. The term was borrowed from
aero-spatial area: the depletion of fuel from a rocket having as consequence the reactor’s
overheating and explosion [1], [2], [3], [4]. By analogy, burnout is characterized by physical and
psychic exhaustion of a person which will consume all his/her energy and “collapse” [1].
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The burnout syndrome’s stages are the following [5], [6], [7], [8]:
• Enthusiasm: it is the “honeymoon” phase, the worker has many expectations and hopes
which are unattainable in relation to his/her work. He/she is enthusiast, manifests an
excessive motivation and exuberant energy. He/she overestimates himself/herself, works
many hours a day and neglects his/her personal life and personal desires.
• Stagnation: the employee understands step by step or brutally that his/her work does not
satisfy all his/her desires. He/she desires to have more time with his/her family or friends,
the satisfaction given by work decreasing gradually and the first symptoms of fatigue occur.
• Frustration: The employee becomes aware that he/she is frustrated by the inability to
change the bureaucratic system, to detach from the sufferings and needs of the patients. The
fatigue, dissatisfaction and irritability become chronical, the worker closes in
himself/herself, doubts his/her competence, develops a sense of personal failure and
complains of various somatic disorders.
• Apathy: The employee becomes more and more disinterested in work and emotionally
detaches from his/her patients. He/she protects himself/herself from avoiding professional
conflicts and challenges, not even being concerned with his/her own physical and mental
health. This period of apathy can prolong considerably.
• Despair: the last phase of burnout. The professional loses all hopes that his/her situation
will develop positively and loses confidence in the future. Some are abandoning their job
while others behave as if they are perfectly controlling the situation and hiding the profound
state of anxiety that they live on daily.
2. Materials and Methods
The study had been prospective, performed in the period between February and April 2019 on
a sample of 180 subjects comprising AIC (Anaesthesia & Intensive Care) physicians, nurse
anaesthetists, nurses and healthcare assistants from ICU (Intensive Care Unit) and from the SU
(Surgical Unit) within Emergency Clinical Hospital of Galati.
MBI (Maslach Burnout Inventory) survey, validated in Romanian language, was self-
administered in order to collect the data [9], [10], [11], [12], [13]. Christine Maslach defines the
burnout syndrome by three major elements [14], [15], [16], [17], [18]:
• Emotional exhaustion – manifested by energy loss, asthenia, mental exhaustion,
demotivation, frustration.
• Depersonalization – represents the interpersonal dimension of the burnout and is
manifested by the loss of empathy towards patients, irritability, culpability and cynicism.
In extreme cases, physical, psychological and social aggressions can be the outcome.
• Reduction of personal accomplishments – it is the component of syndrome’s self-
evaluation. It is manifested by depreciation/devaluation of the activities performed (the
work is not interesting, inefficient in changing the fundamental problems).
The survey comprises 23 items and contains a series of questions with 5 variants of answer. It
is calculated the sum of the points for each dimension, being obtained a score each. This score will
be fit into one of the four intervals:
- between 0-25 points: it is considered a normal score;
- between 26-50 points: it is considered a border line score;
- between 51-75 points: it is considered a burnout score;
- between 76-125 points: it is considered a sever burnout score.
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Summing up the last two intervals will be considered to determine total burnout.
3. Results and Discussions
141 subjects responded out of 180, representing 78.33%. Out of these, a number of 99 subjects
present burnout syndrome, respectively a percentage of 70.21%.
According to the age groups (Figure 1), the highest percentage was registered at subjects
between 30 and 40 years old (81.82%) and the lowest at those comprised between 20 and 30 years
old (33.33%). Resident physicians and debutant nurses are included in this last category, which are
guided in taking the decisions by experienced medical staff (primary physicians, senior nurses),
relieving them somewhat by assuming total decisional responsibility.
81,82%
73,08%
69,84% 69,23%
61,90% 60,00% 60,00%
54,55%
% Burnout
33,33% 33,33%
27,27% % Severe Burnout
% TOTAL Burnout
7,94%
3,85%
0,00% 0,00%
20 - 30 ages 30 - 40 ages 40 - 50 ages 50 - 60 ages < 60 ages

Age groups
Fig. 1. Evaluation of burnout syndrome in AIC personnel per age groups
The evaluation according to the three components of the survey (Figure 2) shows that 73.76%
of the subject’s present emotional exhaustion at an average and high level, 46.81%
depersonalization and 62.42% reduction of personal achievements.
55,32%
53,19%
48,94%
39,72% 37,59%
26,24%
% low level
18,44%
13,48% % average level
7,09% % high level
Emotional exhaustion Depersonalization Reduction of personal

accomplishments
Level types
Fig. 2. Evaluation according to level types in AIC personnel.
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Evaluation of burnout syndrome in AIC physicians

Out of the data analysis (Figure 3), it results that a percentage of 80% from AIC physicians
present burnout syndrome, the most affected being those comprised in the age group between 20
and 30 years old (100%) and those over 50 years old (100%), a lower level belonging to those
comprised between 30 and 50 years old (75%).
100,00%100,00% 100,00% 100,00% 100,00% 100,00%
75,00% 75,00%
62,50%
50,00% % Burnout
% Severe Bourout
25,00% % TOTAL Bourout
12,50%
0,00% 0,00% 0,00%
20 - 30 ages 30 - 40 ages 40 - 50 ages 50 - 60 ages < 60 ages

Age groups
Fig. 3. Evaluation of burnout syndrome in AIC physicians per age groups
The emotional exhaustion reaches the highest level in physicians (86.66%), followed by the
reduction of personal achievements (73.33%) and depersonalization (46.67%).
Evaluation of burnout syndrome in Anaesthesia nurses

Out of a total number of 18 nurses, 10 subjects present burnout syndrome, respectively 55.56%,
the most affected age being the one comprised between 50 and 60 years old (Figure 5). It must be
observed the lowest percentage among all professional categories surveyed, probably due to the
presence of the anaesthesiologist in the surgery theatre and to the fact that the physician assumes
responsibility for the decisions.
Emotional exhaustion (Figure 4) reaches the highest level in Anaesthesia nurses (55.56%),
followed by the reduction of personal accomplishments (27.78%), at equal value with
depersonalization (27.78%).
72,22% 72,22%
44,44%
38,89%
27,78% % low level
22,22%
5,56% % high level
0,00%

accomplishments
Level types
Fig. 4. Evaluation per level types in Anaesthesia nurses
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Evaluation of burnout syndrome in SU nurses and healthcare assistants

This professional category is affected by burnout in a percentage of 65.45%, the emotional
exhaustion being at the highest level (87.09%), followed by the reduction of personal
accomplishments (58.07%) and depersonalization (35.48%) (Figure 5).
58,18%
49,09% 50,91%
47,27%
41,82%
34,55%
% low level

% high level
1,82% 0,00%

accomplishments
Level types
Fig. 5. Evaluation of SU nurses and healthcare assistants per level types
Evaluation of burnout syndrome in Surgery Unit nurses

The results of this study show that the healthcare assistants are the most affected professional
category, 100% presenting this syndrome. The reduction of personal accomplishments was the
component with the highest level recorded (100%) (Figure 6); this is most probably caused by
conflictual interpersonal relations, no team work and deficient support to colleagues.
68,18% 68,18%
59,09%
31,82% % low level

27,27%
13,64% 13,64%
% high level
0,00%

accomplishments
Level types
Fig. 6. Evaluation of ICU healthcare nurses per level types
4. Conclusions
The data from this study show a very high level of burnout syndrome in ICU and SU within
Emergency Clinical Hospital of Galati, much more over the average level accepted by similar
studies. The most affected personnel categories are AIC physicians and ICU healthcare assistants,
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the physicians having the most increased level of emotional exhaustion and the healthcare
assistants the most increased level of reduction of personal accomplishments.
As measures to be implemented on average term, we can mention the supplementation with
medical personnel from these two most affected categories which might improve the existing
problems. Also, psychologic counselling of the subjects, learning about and “training on” team
work, collegial respect at language level and management – employee/employee – employee
attitude, exercises of “team building” type, will succeed in soldering the interpersonal relations
between them.
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The Prevalence of Cognitive Impairment in Patients with Proximal

Femoral Fractures
GOGULESCU Bogdan Adrian1

1Emergency Clinical Hospital “Sf. Ap. Andrei” Galati (ROMANIA)
Email: bgogulescu@gmail.com
Abstract
Introduction
Fractures of the proximal femur are becoming more common. Through the data, this medical
problem became a humanitarian, economic and social has imposed the first evidence-based review
in our clinic. It is necessary to find out if there is a causal relationship between postural instability,
hip fractures and cognitive impairment.
Methods
Clinical data were recorded, removing any information about personal identity. Were included
in the study consecutive patients admitted during the period 01.01.2017-31.12.2017, aged over 65
years and primary fractures of the proximal femur caused by low energy trauma produced by falling
from the same level.
Results
360 cases with a mean age of 78.73 years and having a proximal femoral fracture were analysed.
The prevalence of cognitive impairment was 27.22%, significantly undifferentiated by the type
of fracture or age group. The relatively small age of the batch of 72-100000 indicates the existence
of a socio-economic problem besides the high medical problems raised by a major fracture
occurring in the context of comorbidity of 86.36%.
Conclusions
The existence of proximal femur fractures in elderly people with certain cognitive involution
creates personal dramas and socio-medical problems that require complex studies.
Keywords: Alzheimer’s disease, Dementia, Fracture, Hip fracture, Older person
Introduction
The incidence of proximal femur fractures is increasing in Romania and around the wold. This
“boom” in hip fractures has grown in the context of increased life expectancy an is associated with
a boom in cognitive deficits. after 65 years of age, falls at same level are more common, cognitive
deficit increases from 3% (65-74 years) to 47% (over 85 years) and the prevalence dementia
doubles every 20 years [1].
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There is an increase in life span of people with decreased physical activity, low food intake,
reduced body mass index (BMI), sarcosis and low bone density, chronic drug users, smokers and
alcohol users with increased pictorial and falls on the same level.
The SENECA study [2] linked the self-perception of health to healthy aging and lifestyle.
Inactivity, smoking and inadequate diet increase the risk of death [3].
The medical literature mentions cognitive and visual disturbances, functional limitations with
walking difficulties, arrythmias and orthostatic hypotension among factors that increase postural
instability. Falls on the same level are potentiated by sedative, hypnotic, neuroleptic, antipsychotic,
non-steroidal anti-inflammatory, antihypertensive and cholinesterase inhibitors [4]. The link
between mental state and the rhythm of falling older people remains controversial for those with a
MMSE score over 15 [5] but ovious for those with an MMSE score below 10 with dementia [6].
The evolution of elderly patients is the burden of complications with unfavourable development
in 50% of cases. Deaths reach 18-33% of cases in the first year after hip fracture.
From the point of view of current data, this medical problem becomes a humanitarian, economic
and social problem. The increased incidence of these cases required the first evidence-based
analysis in our clinic. This analysis highlights the prevalence of cognitive impairments in the
medical records of elderly patients with fractures of proximal femur (femoral neck fractures,
petrochanteric fractures and trochanterodyapysis). It is necessary to find out if there is a causal
relationship between cognitive impairment, pictorial instability, mechanism, evolution and
prognosis of hip fractures.
Methods
The study used the database of Orthopaedics-Traumatology Department of a hospital that serves
a population estimated at 500,000 inhabitants.
Was recorded: age, sex, comorbidities, including impaired cognitive status. Any information
related to your personal identity has been removed.
They were included in the study consecutive patients admitted during 01.01.2017-31.12.2017,
aged 65 and primary fractures of the proximal femur caused by low energy trauma produced by
falls on the same level. They excluded patients with fractures caused by high energy and
readmissions after settlement at other times or other services.
Results
Of the 435 patients with proximal femur fractures, 360 patients were enrolled for the study.
The age was oscillated between 65 and 98 years distributed in three age groups: 65-74 years
with 87 cases (36 men and 51 women), 75-84 years with 167 cases (48 males and 119 females),
85-94 years of 103 cases (22 men (8-14-0) * and 84 women (27-52-2) * and 3 cases over 95 years.
Women’s hospitalization of 2.39 times more often (254 women: 51-119-84 * and 106 men: 36-
48-22 *) are correlated with the existence of a larger female population at older ages. There was a
women/man ratio 2.20 in urban and 2.89 in rural areas.
The average age was 78.23 years (69.5 to 77.45-88.11 to 96.33) * 75.15 with the limit’s years
(mean femoral neck) and 80.35 years (average fracture pertrohanteriene). The difference of 5.2
years of pertrohanteriene fractures and the group of femoral neck support classical claims.
The data can be considered as a test trust and validation of the study results. The patients were
from urban 68.61% (247 cases: 77 men and 170 women) and 31.38% of the area (113 cases, 29
men and 84 women). The number of patients in urban areas is 2.18 times higher. The high
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proportion of fractures from urban can be induced by a sedentary lifestyle, with well-dressed man,
quiet, tired and depressed. Scared by the thought of death from heaven, future patient hid in the
house with tension and instability, irritability and insomnia, diabetes and stress, indigestion and
bloating, viruses and cigarettes, amassing a huge deficit of 25OH vitamin D [7].
Hospitalization ranged between 1 day and 60 days with an average of 13.23 days.
The average length of 13.23 days (12,32-15.41 days) and especially mortality of 5% (18 cases:
9 men and 9 women) during hospitalization, reflects the seriousness of the fracture fragility patients
and difficulties the recovery of the fracture lethality can reach 20% in the first year [8].
Falls occur as a result of hazard, cognitive and visual imperfections, orthostatic hypotension at
change of position and medication. Their frequency increases steadily after 65 years and may
interest up to 30% of the contingent. Many falls, hip fractures followed by (12-42%), are produced
in individuals having a limited mobility and fear of falling [9]. It claims that Alzheimer’s disease
increases the risk of falls by 1.2 times for each point MMSE lost between 30 and 22. The stiffness
values, periods of wandering and agitation influence the direction of the fall and “chance” to do a
hip fracture.
The prevalence of cognitive impairment was of 27.22% (98 cases: 41 women and 57 men) with
uneven distribution: 38.67% to 22.44% for men and women. A more serious damage was found in
66.33% of them.
The presence of dementia and Alzheimer’s disease has been certified to 18.05% (65 cases: 24
women and 41 men) of the patients analysed, representing: 22.64% 16.14% of men and of women.
For this difference can be invoked action of smoking, incriminated in diminishing the function of
execution and problem solving, visual-spatial capacity, attention and memory, which leads the
factor risk to 1.79 for those with Alzheimer’s disease and vascular dementia. Cognitive impairment
in 27.22% of cases reflects brain aging involution highlighting participants achieving static and
dynamic postural balance in the elderly with decreased activity levels accompanied by sarcopenia.
Distribution of dementia and Alzheimer’s disease (18.05%) very different urban and rural (19.43%
to 15.04%) supports the influence of environmental factors in cognitive deterioration. The
complications of immobility and increases the development of Alzheimer’s disease by 30%
(Buchner and Larson) raising the three-month mortality.
Cognitive impairment has reached 24.69% (61 of 247) to those from 32.74% in the urban and
rural derived from (37 of 113). The diagnosis of Alzheimer's disease or dementia reached 19.43%
(48 of 247) in the urban and 15.04% (17 of 113cazuri) in the rural areas.
Cognitive impairment was recorded and the sequelae after stroke, pseudobulbar syndrome,
Parkinson’s disease or parkinsonian phenomena in other cerebrovascular disease. In the studied
group there were 9.16% (33 cases) or acute stroke sequelae thereof: 16.03% male (17 cases: 6+6+5)
* 6.29% and women (16 cases: 2+7+7) *. This type of damage was found in 3.74% of urban and
20.35% of those residing in the village. Elderly dementia occurs after micro-infarction small blood
vessel atherosclerotic (multi-infarct dementia). The Hight share (20.35%) of those with stroke and
cognitive impairment compared to those from rural to urban (3.74%) suggests a difference in
monitoring blood pressure and other risk factors. The changes are associated with the reduction of
central muscle followed by slower movement, reducing the length of oscillating stroke member,
accompanied by the doubling of the frequency steps of the period of support. Stride length and
walking speed increased risk of falls and walking in tandem is a predictor of fractures over the next
three years.
Mental balance and stability are positively influenced by a negative vitamins and folic Ac
peripheral neuropathy and musculoskeletal problems in the context of serum parathyroid hormone
creştereii [10]
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The reduction of bone mass and strength of cortical raises risk factor for hip fracture by 19%.
Documented osteoporosis was found in 11.66% (42 cases 7-15 to 20 *) and we can say that
elderly femur became vulnerable to trivial trauma, reduced the “socket” fixation material and
complicated period of functional recovery [11]. Demonstration habitat depending on the age
necessary to supplement the intake of vitamin D for decreasing the rate falls and their consequences
[12]. Regardless of the type, osteoporosis is an independent predictor of fracture [13]. Each fall
with a standard deviation increases the risk 2.6 times reaching risk 8.5 times higher for women
with osteoporosis.
There are significant differences in the Barthel Index, cognitive impairment, dementia,
osteoporosis, Parkinson’s disease, benzodiazepines, antidementia, changes in renal function, heart
rate, ambulance [14]. We are seeing a vicious circle in which the inactivity induce weight reduction
and muscle tone decreases in the tension of the composite beams each side of the limb. Reducing
tension increases the radius of curvature of the long bones requiring remodelling and enlarging
with increasing diameters medullary canals of long bones causing osteoporosis fragile cortices
thickness reduction. The reduction causes decrease of periosteal circulation “shell” fiber reduces
the tensile strength of the areas subject to efforts priming occurs where the fracture. “Slowness”
that occurs postural muscles allow greater trochanter fall on what causes hip fracture. A faster
response to postural muscles determines the buttock fall followed by pelvic fracture (previous
spring) with another chance evolution and survival.
Sarcopenia is usually accentuated by a lower BMI. A decrease indicates an increased risk.
Increasing weight is accompanied by a small reduction in risk. In Alzheimer’s disease weight
loss is attributable to the inability to prepare food, eating, sensory disorders, depression
concomitant energy requirements, social factors and comorbidities. Both the proximal femoral
fractures and cognitive impairment appeared during the existence of other diseases in 86.38% (311
cases), heart rhythm disorders were present in 55 cases (15.27%) representing 13 men (3-55) * and
42 women (6-21-15) *. They affect primarily the age group 75-84 years. The medical literature
correlated with the incidence of hip fractures pointing out that the risk of fracture ethiology of
dementia in Alzheimer’s disease remains constant regardless of the form [1].
Cardiopathies were present in 86 cases (23.88%): 21 males (7-10-4) * and 65 women (9-33-23)
*. Part of the risk of falling is attributable to cardiovascular disease untreated, accompanied by
parkinsonism, fluctuations knowledge, visual hallucinations. Arrhythmias (15.72%) and heart
diseases (23.88%) increases the risk of accidents vascular brain (embolism or bleeding).
Hypertension was recorded in 156 cases (43.33%): 36 men (14-19-3) * and 120 women (30-82-
8) *. Most cases (77.92%) are women (120 of 156). About two-thirds of cases of hypertension
(60.48%) were found in the decade 75-84 years (101 of 167) where hypertensive women reach
68.90% (82 of 119).
Anaemia was found in 33 cases (9, 16%): 11 men (5-4-2) * and 22 women (4-21-6) *. It was
clear that there megaloblastelor involving folic acid deficiency and vitamin B12. These deficiencies
contribute to cognitive aging, but remain present inconclusive evidence [10]. Post-fractures
anaemia and post-intervention potentiate postural hemodynamic changes, index of highlight
behavioural symptoms of dementia and greatly influence rehabilitation and quality of life.
Diabetes was found in 33 cases (9.16%) 5 males (2-2-1) * and 28 women (10 to 12-6) *. Chronic
hepatitis was diagnosed in 24 patients (6.66%) 7 men (3-3-1) It and 17 women (15-0-2) *. The
presence of most cases in the first decade analysed (21 of 24) suggests the possibility of impaired
function by consuming alcohol withdrawal causing some cognitive alterations that reach for this
decade, a rate of 33.33% (29 cases out of 87).
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The coexistence of a hight number of chronic diseases is increased from 83.9% in the decade
65-74 years at 91.50% over 85 years.
Comorbidities recognize the same risk factors, but mutually potentiate each other directly or
through means of treatment [15] influencing the development of the occurrence of hip fractures
from falling.
It comes as two of five patients with hip fracture have a cognitive impairment [16]. It is a reality
that must be talked about. Diagnosis remains poorly documented and requires continuous medical
care. Are common dehydration, electrolyte disturbances, urinary tract infection. Smoking causes
or aggravates respiratory disease, deficiency of vitamin D and by isolation in the apartment,
influence bone density and muscle tone. Treatment of these patients have certain features that
influence the evolution of the fracture, the survival rate and quality of life post fracture. The
correction of vitamin D deficiency reduces muscle weakness, correct the course, decreases the rate
falls, increase the titter of serum alkaline phosphatase and favours increase bone mass recovery.
Physical exercise and a positive influence on the elasticity of the vessel walls vascular
endothelial function, reduced blood pressure and decreases the risk of acute vascular events (stroke
and myocardial infarction).
Effect of physical exercise on falls frequency is discussed. Positive impact on daily activities in
patients with multiple co-morbidities and interval between the time of hospitalization and surgery.
The negative effects of inactivity and obesity induced by treatment with statins are amplified in
terms of vitamin D deficiency, reduced well-being, mobility, life expectancy, increase the risk of
death by cardiovascular complications [17].
Dementia, even in the early stages is a risk factor changes and some medical services programs
of physical activity, because it is conducted safely and reach the goal [18].
It is known that older people are traumatized waiting time in emergency departments of
hospitals, especially if they are brought by ambulance. They feel the need for timely information
to limit environmental effects “hostile” and avoid the depression [19]. In postoperative pain
management is difficult [20] which adversely affect recovery. During this period there were
numerous complications: delirium, pressure ulcer, operative wound infections, urinary and
respiratory infections with high mortality [21, 22, 23].
For patients with cognitive involution, the role of the family is important. Their family know
the behaviour of these patients and they can help medical team recovering the patient with fracture
and cognitive involution [24].
Agitation and falls are reduced if care staff is experienced and familiar with such patients [25].
Depression is associated with reduced activity and osteoporosis. It differs hard apathy increases
the risk of dementia and Alzheimer’s disease, especially when using antidepressants.
Antipsychotics, anxiolytics and inhibitory cholinesterase may induce syncope and bradycardia
accompanied by falls and hip fractures.
Delirium, another clinical event undervalued, has significant effect in assessing the present state
and evolution of the injured elderly. Often considered as a defining element of withdrawal, he may
be the result of psychological trauma during hospitalization, perioperative ion imbalance, anaemia
and transient or persistent hypotension.
In the postoperative period can involve 35-65% of cases can persist for months and often
exposes a dementia or Alzheimer’s disease. He has character predictor of admission in a nursing
home and mortality at one year [26]. Cognitive decline worse or causing extrapyramidal highlights
motoneuron destruction apraxia is exacerbated by stress. Those with parkinsonism frequently
change their steps a little boost and less than 6 feet per minute forecast fall followed by a hip
fracture.
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Cognitive impairment limits functional recovery and return to the spre-accident stages. Only a
proper management of this life-saving leads to a good functional recovery, reduce material costs
and social [27].
The 18 deaths during the study: 9 men and 9 women illustrates the severity of the condition
occurs in patients with heavily loaded pathological. Pre-existing pathology is a risk factor for falls
unforced, followed by fractures at the same level. The significant difference between the deaths of
men with pertrachanteric fracture (7.81%) and the deaths of women (2.7%) coincides with a
significant difference in cognitive involution (21.87% to 9.03%). In men the most common deaths
are recorded in the age group 75-84 years (10.93%) and the most frequent deaths in women are in
the age group 85-94 years (3.70%) which overlaps over the difference in life expectancy between
the sexes,
Conclusions
Dementia and hip fractures are common in the elderly and is associated with high morbidity and
increased mortality in hospital in the first three months it reaches even 30% of cases and one year.
At 5 years 50% of the cases died. The existence of proximal femur fractures elderly with definite
involution cognitive create personal dramas and socio-medical problems that require new studies
complex.
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Age
Average Age per group and Global
Age Neck femoral fractures Petrchanteric fractures Tohanterodyafizar fractures

M F IC E M F IC E M F IC E
65-74
75-84 Case 360 Men 106 Women 247
85-94
The distribution of cognitive impairment
Total general 360 98 27,22%
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Distribution of cognitive involution in urban san rural areas
70
60
50
40
D+A
30
AVC+P
20 Total
10
0
U R Total % U R Total % U R Total %
Fractura de col femural Fractura petrohanteriana Fractura
trohanterodiafizara
Total 360 98 27,22%
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Burnout Risk Evaluation in Medical Oncology – Radiotherapy

Personnel
REBEGEA Laura1,2, TARLUNGIANU Camelia1

1Department of Medical Oncology-Radiotherapy, “Sf. Ap. Andrei” Emergency Clinical Hospital, Galati, (ROMANIA)
2Medical Clinical Department, Faculty of Medicine, “Dunarea de Jos” University of Galati, (ROMANIA)
Emails: laura_rebegea@yahoo.com, tarlungianucamelia@yahoo.com
Abstract
Introduction
Even if, all studies evidenced that Burnout syndrome affects medical personnel from all medical
specialties, the highest prevalence is in surgical, oncological and emergency medical specialties.
Scope
Burnout syndrome evaluation in Medical Oncology and Radiotherapy personnel.
Method and Material

This study has involved 50 persons employee in Medical Oncology and Radiotherapy
Department, from all categories: 11 superiors personal (medical doctors, physicists, psychologist),
31 nurses, and 8 auxiliary personnel (stretcher-bearer). The following questionnaires were used:
professional exhaustion level questionnaire (with 25 items), questionnaire for attitude and
adaptation in stressed and difficulties situations, BRIEF COPE and SES scale.
Results
After professional exhaustion level questionnaire for superior personnel, emotional exhaustion
prevalence, followed by reduced personal achievement and an accentuated increasing of affecting
grade after first year of activity, with a pick around 10 years of activity were revealed. For nurses,
share of depersonalization is relative homogenous, in moderate – low limits. The results revealed
that 56% of personnel from this study have risk for burnout syndrome developing, without any
prevention methods and 12% has already burnout syndrome.
Conclusions
In general, this syndrome is under evaluated and under-diagnosed and its incidence can be
diminishing by using the techniques of stress resistance, psychological counselling, cresting a
friendly and tolerant professional climate.
Keywords: Burnout Syndrome, questionnaire, depersonalization
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Introduction
The stress is an omnipresent element of the modern world and the professional stress, an
undeniable reality. What are specific for today’s Romanian society are the substantial increase in
stress levels and an increase in the proportion of responses to stress factors. The phenomena’s
definition is hard to be said, being a complex and abstract concept.
In 1926, Hans Seyle defines stress [1] as being a general syndrome of adaptation respectively
the non-specific response of the body to a specific request which it is subject. Also, he has
introduced the terms of eustress (the optimal level of stress that can motivate or increase individual
performance), distress (when requesting the individual becomes critical) and has identified 3
stages of stress’s evolution, being alarm, resistance and exhaustion.
The concepts and definitions the term burnout is relatively new and was defined in 1974 by
Herbert Freuderberger as: “the disappearance of motivation or incentive”, especially when the
devotion to a cause or relationship falls to produce desired results [2].
The professional stress (PS) appears when there is a discrepancy between the requirements of
the work environment and the individual’s ability to do it or keep them under control. Regardless
of stressors agents, PS is firstly based on a strong affective participation.
After Maslach (1986) a person with Burnout Syndrome (BS) is a person who over the course of
several weeks notices his own exhaustion, shows a considerable decrease in performance,
experiences alienation experiences with his person, colleagues, and the institution [3].
The term burnout is heterogeneous, and cannot be spoken about a specific pathology, but a
minimal clinical picture is acceptable, with the following aspects: signs and somatic symptoms
(continual headache, gastrointestinal disorders, asthenia, fatigue), unusual behaviours for the
subject (irritability, intolerance and inability to understand or be empathetic to others, unjustified
criticism, lack of trust, attitude of superiority to others), defensive attitude (rigidity, negativism,
resistance to change, pseudo activism-subject spends more hours at work but he realizes less of
what he proposes).
Other symptoms/signs of excessive stress are anxiety, depression, and loss of interest for the
job, sleep disorders, concentration issues, muscle tension, social withdrawal, and the use of alcohol
or drugs, loss of sexual appetite, decreasing immunity. It is accepted that BS has a staged evolution:
stage 1 is characterized by restlessness, confusion and the appearance of frustration (the perception
that something is wrong), stage 2, characterized by intense frustration and discontent, stage 3
characterized by apathy, disclaimer and desperation.
Without being a precise clinical entity, the burnout is centered on the tripod: physical and/or
mental exhaustion, professional depersonalization and negative attitude toward one’s own
accomplishments.
Fengler (2016) identifies 7 levels that may contain factors involved in the occurrence of
Burnout: (1) the person himself, (2) private life contexts, (3) professional contacts, (4) team and
the circle of colleagues, (5) contact with superiors, (6) the institution and its branch, (7) social
framework conditions [4]. Examples of contributing factors: remanence of negative affective
states, too big expectations, too much work, unsatisfactory results, increased effort without results,
lack of shelter and hope in remedying the situation, requests with opposing motives, conflicts with
bosses or mates.
Medical doctors and professional psychological pathology

The professional category which is the most affected by BS is medical doctors. It was found
that this is the result from the individual’s permanent obligation to sustain an idealized personal
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image, the lack of a proper social recognition with the degree of difficulty of the activities carried
out, unconventional time schedule, lack of immediate reward due to the work done, lack of
knowledge of the quality of the activity, lack of encouragement and moral gratifications, Under
these conditions, the subject is exhausted as it finds the collapse of its own illusions in the face of
reality’s evidence. Medical specialists where the BS is more common are surgeons, oncologists,
and psychiatrist. Toker et al., performed in 2012 a prospective study in which the BS has been
identified as a risk factor for the subsequent incidence of heart disease [5]. Studies show that the
oncologist who is in direct contact with the cancer patient changes unconsciously both his
professional behaviour and his self-image under the permanent pressure of the situations he faces.
He is emotionally charged after the intense transfer takes place in the doctor – patient
relationship (a paradoxical patient who at the same time desires despair by over – invigorating the
physician’s potency, but also regaining autonomy, minimizing the help received.
Method and Material
This study has involved 50 persons employee in Medical Oncology and Radiotherapy
Department, from all categories: 11 superiors personal (medical doctors, physicists, psychologist),
31 nurses, and 8 auxiliary personnel (stretcher-bearer). The following questionnaires were used:
professional exhaustion level questionnaire (with 25 items), questionnaire for attitude and
adaptation in stressed and difficulties situations, BRIEF COPE and SES scale.
The survey aims to assess the prevalence and risk of installing BS in staff of the Medical
Oncology and Radiotherapy Clinic. For this, the following tools were used: questionnaire
evaluating the level of professional exhaustion, emotional exhaustion, depersonalization, reducing
personal achievements, adaptive questionnaire and attitudes in difficult or stressful situations
BRIEF COPE, scale SES.
Results
Applying the assessment questionnaire to the level of professional exhaustion revealed the
following: higher staff: of the three measured dimensions, in most situations, emotional exhaustion
is prevalent, followed by a reduction in personal achievements. There is a marked increase in the
degree of damage after the first year of activity, with a peak around 10 years old, following a
downward trend, with a plateau phase around 25 years of activity. It is possible that the decrease
is due to the use of more efficient method of coping. Degree of depersonalization had relative
reduced scores. Nurses with university education are a category in which motional exhaustion and
personal achievement are very close in value. Depersonalization rate is relatively homogeneous
and in low-moderate limits. Nurses without university education had depersonalization rate in
relatively homogeneous values (low-moderate). Degree of emotional exhaustion had a constant
growth with a peak around 15 years of seniority and maintenance. For 50% of case in this category,
the highest scores were obtained in the dimension “reduction of personal achievement”. In auxiliary
personnel (stretcher-bearer) is remarkable the prevalence of personal achievement along with
emotional affecting in short time after beginning of activity.
Assessing the affecting grade, on personal categories, we observed that the most affected
personnel category is represented by nurses with university education. Nurses without university
education are more frequent affected, followed by medical doctors. Risks for professional
exhaustion syndrome development for medical doctors, physicists and psychologist were 27.27%
– low total score, 54.55% – medium total score, and 18.18% – high total score (Fig. 1).
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Affecting grade for superior personnel: medical

doctors, physicist, psychologist
Medium total
score
54.55%
Low total
score
27.27% High total
score
18.18%
Fig. 1. Affecting grade for superior personnel: medical doctors, physicist, psychologist
Affecting grades for nurses with university education were 40% – low total score, 30% –
medium total score, and 30% – high total score (Fig. 2).
Nurses with university studies

4,5
Low total
4
score
3,5 4 Medium total High total
3 score score
2,5 3 3
2
1,5
1
0,5
0
Fig. 2. Affecting grades for nurses with university education
Affecting grades for nurses without university education were 19% – low total score, 76% –
medium total score, and 5% – high total score. Affecting grades for auxiliary personnel (stretcher-
bearer) were 63% – low total score, 37% – medium total score. From charged self-efficacy point
of view, the scores are situated, in general, in superior range, with specification that the higher
scores are found in nurses without university education.
Comparative analysis of total affecting grade did not indicate significant differences between
superior personnel group vs. nurses with university study group, p=0.85, and between nurses with
university study group vs. nurses without university study group, p=0.84.
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These results are positively correlated with coping mechanism based on active adaptation and
positive reframing for medium and superior personnel, and most frequent, planning for auxiliary
personnel.
Discussions
These results have only a statically value indicating the level of professional stress from Medical
Oncology and Radiotherapy Clinic. The evaluation revealed that 12% of participating personnel is
affected by BS, 56% of them had different grades of risk for BS development, in near future,
without any preventive actions. The dimensions involved in BS development are emotional
exhaustion, reducing of personal achievement and depersonalization.
Emotional exhaustion is the most frequent in affecting grade at all categories. The contributing
factors are time spent with patients and affective involvement, assisting patients with hard pain,
unreasonable requirements from patient’s family, professional climate, difficulties in relation-
ships, bad communication, and no right to do a mistake. Personal achievement reducing is more
frequent in nurses and auxiliary personnel. The contributing factors are: high workload, high and
permanent pressure. Depersonalization is characterized by decreasing of human relationships. The
contributing factors are: lack of polite, tensioned and aggressive relationships, lack of solidarity.
Panagioty et al., [6] performed a metanalysis which included 47 studies on 42 473 physicians.
Physician burnout was associated with an increased poorer quality of care due to low
professionalism (OR, 2.31; 95% CI, 1.87-2.85), with patient satisfaction decreasing (OR, 2.28;
95% CI, 1.42-3.68) and with an increased risk of patient safety incidents (OR, 1.96; 95% CI, 1.59-
2.40). Physician burnout is 3 times more likely to receive low satisfaction ratings from patients
associated with suboptimal patient care, twice as likely to deliver suboptimal care to patients owing
to low professionalism and twice as likely to be involved in patient safety incidents [6, 7]. The
depersonalization dimensions of BS have the most adverse association with the quality and safety
of patient care and with patient satisfaction. The association of burnout with low professionalism
was particularly strong among studies based on residents and early career physicians [6, 7]. Antoni
Font et al., [8, 9, 10] performed a study which aim was to describe the prevalence of burnout in a
sample of oncology health professionals and to rate their related job satisfaction; in this study 115
professionals answered the Maslach Burnout Inventory and the results revealed that 36.9% of
respondents presented high emotional exhaustion values and 22% show high characteristics of
depersonalization in relationships. In a cross-sectional study performed by Sibyl Kleiner and Jean
E. Wallace [11] on oncologists from across Canada (n=312) the questionnaires were completed for
assessing burnout, compassion fatigue, workload, time pressure at work, work-family conflict, and
other personal, family, and occupational characteristics. The results of this study showed the
oncologists’ subjective perception of time pressure at work is a key predictor of their burnout and
compassion fatigue, and closely linked to work-family conflict. Other independent predictors of
burnout are family and occupational characteristics; parenthood (negatively associated with
burnout), working in an academic setting, and treating sarcoma, are both negatively associated with
burnout, while treating breast cancer is positively associated with burnout. Women report higher
levels of burnout, even net of subjective and objective workload. Also, Kleiner and Wallace
reported that compassion fatigue is a phenomenon typically understood to encompass both being
too tired to care, and “having to forgo [one’s] sense of compassion in an effort to protect [ones]
self from despair” [11].
Regarding BS among nurses, Bourdeanu et al., [12] made a study on 193 participants – oncology
and haematology nurses (97.9% female, 51.8% teaching hospital, 55.4% Urban). Emotional
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exhaustion, depersonalization and personal accomplishment, respectively were find in 31.09%,

9.3%, and respective 20.73% of participants. Oncology and haematology nurses with higher levels
of emotional exhaustion are more likely to express intent to leave the profession, 17% of
responding cases indicated intent to remain despite high levels of emotional exhaustion. Age,
employment status, ability to schedule days off, and relationship with physicians were significant
associated with emotional exhaustion. Higher levels of EE were associated with a greater intent to
leave the profession within near future [12]. Burnout syndrome should be considered an indicator
of the health of the haematology/oncology nurses with an enormous impact on daily quality of life
and may affect the patient care [12].
Professional stress management may be done with changes at three levels: (1) modifying of
organizational structure and process of work, (2) improvement of relationships between
organization and each medical doctor, through professional development programs, (3) individual
actions for stress reducing.
There are some adapting strategies of stress using techniques for development of stress
tolerance, maintaining positive self-esteem, maintaining the emotional equilibrium, development
of satisfactory relationship with the others [13, 14, 15, 16].
Conclusions
In general, work overload and organizational problems seem to be the main difficulties as well
as communication and emotional aspects with patients and colleagues. The oncologists are
particularly at risk for mental health problems due to the emotionally demanding nature of their
work, report higher levels of burnout than other cancer care staff. The oncology specialty has been
rated by physicians as a field producing “high” levels of emotional exhaustion. BS is under
evaluated and under-diagnosed and its incidence can be diminishing by using the techniques of
stress resistance, psychological counselling, cresting a friendly and tolerant professional climate.
REFERENCES
1. https://www.stress.org/about/hans-selye-birth-of-stress
2. http://jb-schnittstelle.de/wp-content/uploads/2014/08/Burned-Out.pdf.
3. https://spssi.onlinelibrary.wiley.com/doi/abs/10.1111/j.1540-4560.1974.tb00706.x.
4. Fengler J. Helping to tire-burn in work. Gdansk: Gdanskie Wydawnictwo Psychologiczne.
5. Toker S, Melamed S, Berliner S, Zeltser D, Shapira I. Burnout and risk of coronary heart disease: a
prospective study of 8838 employees. Psychosom Med. 2012 Oct; 74(8): pp. 840-7.
6. Maria Panagioti, Keith Geraghty, Judith Johnson, Anli Zhou, Efharis Panagopoulou, Carolyn Chew-Graham,
David Peters, Alexander Hodkinson, Ruth Riley, Aneez Esmail. Association Between Physician Burnout and
Patient Safety, Professionalism, and Patient Satisfaction A Systematic Review and Meta-analysis. JAMA
Intern Med. doi:10.1001/jamainternmed.2018.3713
7. Maslach C, Jackson S, Leiter M. Maslach. Burnout Inventory Manual. Palo Alto, CA: Consulting
Psychologists Press; 1996.
8. Antoni Font, Vanessa Corti, Rita Berger. Burnout in Healthcare Professionals in Oncology. Procedia
Economics and Finance 23 (2015) pp. 228-232.
9. Maslach, C. (2009). Understanding Burnout. Ciencia y Trabajo, 11 (32), pp. 37-43.
10. Maslach, C., Schaufeli, W. B., & Leiter, M. (2001). Job burnout. Annual Review of Psychology, 52, pp. 379-
422.
11. Sibyl Kleiner and Jean E. Wallace. Oncologist burnout and compassion fatigue: investigating time pressure
at work as a predictor and the mediating role of work-family conflict. Kleiner and Wallace BMC Health
Services Research (2017) 17: p. 639.
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12. https://sigma.nursingrepository.org/bitstream/handle/10755/603307/2_Pieper_B_p75634_1.pdf?sequence=1
&isAllowed=y
15. Lupu, V. V., Ignat, Ancuta., Paduraru, Gabriela., Ciubara, A., Ioniuc, I., Ciubara, A. B., ... & Burlea, M.
(2016). The study of effects regarding ingestion of corrosive substances in children. Rev Chim, 67, pp. 2501-
3.
54, p. 66.
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The Prevention of Dementia Before and After Stroke
FĂTU Ana-Maria1, PÂSLARU Ana-Maria1, SÂRBU Fabiola1,

CREANGĂ-ZĂRNESCU Valerica1, CIUBARĂ Anamaria 2
1PhD Student at University “Dunărea de Jos”, Galați, (ROMANIA)
2PhD Department of Psychiatry, Faculty of Medicine and Pharmacy, “Dunărea de Jos University”, Galaţi, (ROMANIA)
Email: annapaslaru@gmail.com
Abstract
Introduction
Dementia is an important public health problem, the only cause of death that cannot be treated
or cured. In 2018 the number of people living with dementia was estimated at 50 million (about
5% of the world population), a new case is diagnosed every 3 seconds. Prevalence of dementia is
increasing, both before and after stroke.
Aim
The purpose of this paper is to emphasize the importance of early identification of the risk
factors associated with cognitive decline and the role of the complex health care approach
Method
The study was retrospective for a period of 6 months. Sixty patients with main diagnosis of
stroke were included in the study, and secondary dementia diagnosis. In addition, an analysis of
randomized controlled trials data from the literature, on preventing cognitive deficits has been
performed.
The results showed that more women are affected by this debilitating disease, of which 72%
were over 80 years old. The following modifiable risk factors were identified: 63% of patients had
hypertension, 42% had recurrent stroke, 37% atrial fibrillation, 26% type II diabetes, 22%
dyslipidaemia, and 10% obesity.
It is believed that one third of cases can be prevented by early identification of risk factors,
especially cardiovascular, and by increasing the efficiency recovery after stroke. This can be done
before the onset of the disease, increasing the cognitive reserve of healthy people and delaying the
development of pathological changes in the brain.
In elderly subjects, healthy diet, moderate physical activity, chronic stress reduction, social
interaction along with improvement in cardiovascular risk factors, could be considered the first line
of defense against the development and progression of dementia.
Conclusions
The pathological process begins long before it manifests itself clinically, thus providing the
opportunity to identify or combat the prodromal stages of the disease forward. We recommend
multifactorial intervention to prevent cognitive impairment and dementia.
Keywords: dementia, stroke, prevalence, risk factors, prevention, cognitive decline
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General Notions
Stroke is a risk factor for dementia and dementia predisposes to stroke. [1] Current evidence
suggests that 25-30% of stroke survivors develop immediate or delayed vascular cognitive
disorders leading to dementia. [2] The states of cognitive dysfunction prior to cerebral infarction
are described under the umbrella of a progressive care dementia involving insidious
neurodegenerative processes and vascular changes. [3]
The population has become worried about the effects of memory loss as much as it is worried
about cardiovascular disease or diabetes. Dementia is overwhelming not only for people who have
it, but also for their families and caregivers. There is a lack of awareness and understanding of
dementia in most countries, leading to stigmatization, barriers to diagnosis, and physical,
psychological and economic impact on the whole of society. [4]
The World Health Assembly recognizes that dementia is a priority issue, endorsing in 2017 a
global action plan aimed at preventing this disadvantaged disease and providing support to the sick.
[5]
Age – Non-Modifiable Risk Factor of Dementia
There is no curative treatment, but epidemiological research provides a substantial amount of

risk factors and modifiable protection that can be addressed to prevent or delay the onset of
dementia. [6]
We performed a six-month retrospective study in the Department of Neurology at the
Emergency County Hospital “St. Apostol Andrei” Galati, in which we included 60 patients with
main diagnosis of stroke, and secondary diagnosis of dementia. We have analysed the modifiable
and non-modifiable risk factors that predispose or aggravate dementia in patients who have had a
cerebral infarction.
As the life expectancy increases, the number of people living with dementia increases, so the
incidence correlates with age, with a major leap after 60 years. In Figure 1 the results show that
female sex was the most affected by this disabling disease, of which 72% were over 80 years old.
Fig. 1. Incidence of dementia by gender and age in stroke
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Although it occurs in people older than 60 years, dementia is not a normal, inevitable aging of
the brain, 9% of cases being reported among young people over 30 years. [7]
Modifiable Risk Factors for Dementia
The Rotterdam study showed that the seven different risk factors involved in developing
dementia include smoking, the environment of obesity, physical inactivity, low levels of education,
diabetes, hypertension and major depressive disorder. The cumulative data from this study
suggested that when these 7 factors were approached properly, a 30% reduction in dementia
incidence was possible. [8]
In Figure 2 we underline the modifiable risk factors of the patients included in the study: 63%
of patients suffer from arterial hypertension (AH), 42% had stroke recurrence, 37% atrial
fibrillation (AF), 26% type II diabetes mellitus, 22% dyslipidaemia and 10% obesity.
Fig. 2. Modified risk factors for dementia associated with stroke
More studies investigate the impact of reducing the modifying risk factor on the health risk of
brain, cognition and dementia. [9]
FINGER is the first randomized controlled trial in 1,200 patients for 2 years showing that it is
possible to prevent cognitive decline by using multifactorial intervention among the elderly. The
results highlighted the value of the modified risk factors approach as a strategy to protect the health
of the brain. [10]
The Mediterranean diet based on the consumption of unsaturated fats in fish, cereals, fruits and
vegetables associated with salt, sugar and alcohol reduction has beneficial effects on memory,
language, executive function and is also in line with the recommendations on reducing
cardiovascular risk disease. DASH Diet Association, for hypertension, can have a major impact on
cognitive decline in older people. [11]
According to the Finnish study the aerobic exercise (walking, running, gymnastics), postural
and muscle growth for the 8 main muscle groups, performed regularly, 30-60 min, 3-4 times a
week, slows progression to dementia. [12] Elderly with a normal cognitive function that performed
regular exercises with moderate intensity exhibited a lower risk of cognitive decline over 8 years.
[13] In people with cognitive impairment exercise can improve spatial and verbal memory. [14]
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The negative impact of chronic psychosocial stress and charged on cognition can be countered
that interventions, such as regular meditation or yoga, aimed at controlling the level of stress.
Cognitive recovery is a complex therapeutic intervention that plays an essential role in the
multidisciplinary rehabilitation of dementia, consisting of individual therapy with the
neuropsychologist, group-based training and computer cognitive training, strategies that emphasize
the improvement of daily life and social interaction. [15]
Depression is a highly prevalent disorder affecting every age and population, that influence
attention, psychomotor speed and executive function with repercussions on cognitive function with
aging. [16] Depression should be recognized and treated properly, both by pharmacological means:
selective serotonin reuptake inhibitors, tricyclic antidepressants (with low efficacy in the elderly
and increased risk of ischemic or haemorrhagic stroke), but notably by non-pharmacological
therapies.
Improving predisposing conditions for vascular pathology, such as hypertension, dyslipidaemia
and diabetes, can be an important target for preventing dementia. A meta-analysis concluded that
antihypertensive treatment could only decrease the risk of vascular dementia, but not Alzheimer’s
dementia or cognitive decline, with negative in examining subjects without vascular disease. [14]
Patients with diabetes mellitus type II have up to three times the risk of developing dementia,
even after adjusting for other vascular risk factors. [18] Diabetes accelerates microvascular
pathology in the brain, also causing cognitive impairment through fluctuations in glucose and
insulin levels in the blood that may affect beta amyloid clearance. [19]
Atrial fibrillation is associated with the risk of stroke, and patients with stroke have higher rates
of progressive cognitive impairment and dementia. [20] If macro- and micro-cerebral ischemic
events are significant mechanisms underlying the association of AF with dementia, then the
initiation, use and efficacy of anticoagulation is critical. [21] Patients treated with anticoagulants
at the time of FA diagnosis have a 29% lower risk of dementia than patients without medication,
according to the latest studies. [22]
There is currently limited evidence to support the role of drugs used for dyslipidaemia, namely
statins, in preventing cognitive decline or dementia. Instead, statins lower LDL cholesterol and
may have a beneficial effect on platelet function, endothelial activity and inflammation to prevent
stroke. [23]
A recent meta-analysis showed that repetitive transcranial magnetic stimulation and direct
transcranial current stimulation can significantly improve cognitive function in both, healthy older
adults and dementia patients, repeated sessions being more effective in improving knowledge than
were single sessions, suggesting needed sustained treatment to alter brain function [24, 25].
Conclusion
The pathological process begins long before it manifests itself clinically, thus providing the
opportunity to identify or combat the prodromal stages of the disease forward. We can act to reduce
the modifiable factors risk which, most of time, are common in stroke and dementia. A
multifactorial intervention that includes regular exercise and a healthy diet, along with
improvement in vascular risk factors, psychosocial stress, and major depressive episodes may be
most appropriate to prevent cognitive decline.
However, we need randomized trials on larger groups of people to demonstrate certain
preventive interventions benefit of people at risk.
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REFERENCES
1. Pendlebury, ST. (2012) Dementia in patients hospitalized with stroke: rates, time course, and clinico-
pathologic factors. Int J Stroke 7(7), p. 570.
2. Kalaria, R.N., Akinyemi, R., and Ihara, M. (2016) Stroke injury, cognitive impairment and vascular dementia.
Biochim Biophys Acta. 1862(5), pp. 915-925.
3. Kalaria, R.N., Akinyemi, R., and Ihara, M. (2016) Stroke injury, cognitive impairment and vascular dementia.
Biochim Biophys Acta. 1862(5), pp. 915-925.
4. https://www.who.int/news-room/fact-sheets/detail/dementia
5. Patterson C. (2018) World Alzheimer Report 2018: The state of the art of dementia research: New frontiers.
Alzheimer’s Disease International. https://www.alz.co.uk/research/WorldAlzheimerReport2018.pdf
6. Mangialasche, F., Kivipelto, M., Solomon, A., & Fratiglioni, L. (2012) Dementia prevention: current
epidemiological evidence and future perspective. Alzheimers Res Ther, 4(1), p. 6.
7. https://www.who.int/news-room/fact-sheets/detail/dementia
8. De Bruijn, R.F., Schrijvers, E.M., & De Groot, K.A, (2013) The association between physical activity and
dementia in an elderly population: the Rotterdam Study. Eur J Epidemiol. 28, pp. 277-283.
9. Rakesh G, Szabo ST, Alexopoulos GS, & Zannas AS. (2017) Strategies for dementia prevention: latest
evidence and implications. Ther Adv Chronic Dis, 8(8-9), pp. 121-136.
10. Rakesh, G., Szabo, T., Alexopoulos, G.S., & Zannas, A. (2017) Strategies for dementia prevention: latest
evidence and implications, Ther Adv Chronic Dis, 8(8-9), pp. 121-136.
11. Morris, MC., Tangney, CC., & Wang, Y. (2015) MIND diet associated with reduced incidence of Alzheimer’s
disease. Alzheimers Dement, 11, pp. 1007-1014.
12. Kivipelto, M., Solomon, A., Ahtiluoto, S., Ngandu, T., Lehtisalo, J., Antikainen, R., Bäckman, L., ... &
Soininen H. (2013 )The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability
(FINGER): Study design and progress Alzheimers Dement. 9(6), pp. 657-665.
13. Chu, DC., Fox, KR., & Chen, LJ. (2015) Components of late-life exercise and cognitive function: an 8-year
longitudinal study. Prev Sci, 16, pp. 568-577.
14. Nagamatsu, LS., Chan, A., & Davis, JC. (2013) Physical activity improves verbal and spatial memory in older
adults with probable mild cognitive impairment: a 6-month randomized controlled trial. J Aging Res, 3, pp.
179-192.
15. Stern, Y. (2012) Cognitive reserve in ageing and Alzheimer’s disease. Lancet Neurol ,11, pp. 1006-1012.
16. Butters, MA., Becker, JT., & Nebes, RD. (2000) Changes in cognitive functioning following treatment of
late-life depression. Am J Psychiatry, 157, pp. 1949-1954.
17. Chang-Quan, H., Hui, W., & Chao-Min, W. (2011) The association of antihypertensive medication use with
risk of cognitive decline and dementia: a meta-analysis of longitudinal studies. Int J Clin Pract. 65, pp. 1295-
1305.
18. Ott, A., Stolk, RP., & Hofman, A., (1996) Association of diabetes mellitus and dementia: the Rotterdam
Study. Diabetologia, 39, pp.1392-1397.
19. Bruce, DG., Harrington, N., & Davis,WA. (2001) Dementia and its associations in type 2 diabetes mellitus:
the Fremantle Diabetes Study. Diabetes Res Clin Pract. 53, pp. 165-172.
20. Bunch, J., Galenko, O., Graves, K.G., & Jacobs,V., May, T.H. (2019) Atrial Fibrillation and Dementia:
Exploring the Association, Defining Risks and Improving Outcomes. Arrhythm Electrophysiol Rev. 8(1), pp.
8-12.
21. Thacker, EL., McKnight, B., & Psaty, BM. (2013) Atrial fibrillation and cognitive decline: a longitudinal
cohort study. Neurology, 81, pp. 119-125.
22. Friberg, L., & Rosenqvist, M., (2018) Less dementia with oral anticoagulation in atrial fibrillation. Eur Heart
J, 39, pp. 453-460.
23. Collins, R., Armitage, J., Parish, S., Sleight, P., & Peto, R. (2004) Effects of cholesterol-lowering with
simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other
high-risk conditions. Lancet, 363(9411), pp. 757-767.
24. Hsu, W., Ku, Y., & Zanto, TP. (2015) Effects of non-invasive brain stimulation on cognitive function in
healthy aging and Alzheimer’s disease: a systematic review and meta-analysis. Neurobiol Aging, 36, pp.
2348-2359.
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Factitious Disorders – Challenges in Psychiatric Diagnosis
ROSU Ioana1, VOINEA Alina Ioana, NECHITA Petronela,

CIUBARA Anamaria
1 “Socola” Institute of Psychiatry, Iasi, (ROMANIA)
2 “Dunarea de Jos” University of Galati, (ROMANIA)
Abstract
Introduction
Factitious disorders are a group of psychiatric pathologies in which a person acts as if they have
an illness by deliberately producing or exaggerating symptoms on them, or sometimes they use a
“victim” in order to catch the attention of the others. Usually the real causes for this kind of
behaviour are emotional impairments and personality disorders. Munchausen syndrome and
Munchausen by proxy syndrome are the most known of this disorder.
Aim
The aim of this presentation is to raise the awareness for this kind of disorders because they are
an extensive problem for the medical system and in many cases, they are hard to diagnose and
manage.
Method
We started by observing and documenting an unusual case of Munchausen syndrome at a patient
from Infantile Neuropsychiatric Clinic of Institute of Psychiatry “Socola”, Iasi and her mother with
Munchausen by proxy syndrome. We compered this pair of cases with data reviews on the subject
to see what are the challenges that are common in this kind of pathologies and haw we can manage
them.
Conclusions
We concluded that factitious disorders are more common that is thought they are. Doctors tend
to let this diagnose on the last place because the priority is to resolve the somatic symptoms of the
patient. That is why we have to acknowledge and understand how to manage this kind of mental
disorders.
Keywords: Factitious disorders, Munchausen syndrome, Munchausen by proxy syndrome
Introduction
Factitious disorders (FD) is a group of psychiatric pathologies in which a person acts as if they
have an illness by deliberately producing or exaggerating symptoms on them, or sometimes they
use a “victim” in order to catch the attention of the others. The patients are with FD usually fabricate
symptoms, “act out” medical conditions and even intervein with medical diagnostic investigation
or trying to manipulate them. Sometimes they self-induce injuries putting themselves in a real
danger. This kind of patients costs the healthcare system considerable amount of money. In United
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States a patient with FD can bring to the healthcare system cost between 200.000 and 1.000.000 $
[1], [2] because they are so difficult to detect and that is why there is a need for improving and
speeding up the diagnostic and therapeutic methods.
Because of this impairment the exact prevalence of FD is hard to establish, but the general date
suggests that between 0.6 and 3% of referrals from general medicine to psychiatry and between
0.02% and 0.9% of cases reviewed in specialist clinics [3]. A study conducted on physicians
reported that the prevalence of FD on their patients is 1.3% [4].
In the anamnestic examination of patients with FD there are usually found emotional traumas,
family disorders, abuse, unresolved/active grief, familial conflicts [5]. This is why, we can also see
that FD could be a coping mechanism to which the patients reach in order to fulfil the emotional
needs they have. It is difficult to imagine how someone can reach to painful methods or invasive
procedures for the attention-seeking, but we must see the FD in all of their socio behavioural
variables.
Another aspect that we should consider when we are evaluating a potential patient with FD is
the clinician’s responses to them. Sometimes the clinicians them to compulsive find or demonstrate
that is something indeed physically wrong with that patient.
Diagnose Criteria for FD
There are 2 guidelines of diagnosis currently used: one is the European guideline ICD-10
(International Classification of Disease-10th edition) and DSM-5 (The Diagnostic and Statistical
Manual of Mental Disorders-5th edition), the American guideline.
In ICD-10 FD are under the code F68.1 in the category “Other personality and behaviour
disorders of the adult”. Here, the criteria of diagnose is that the patient is inventing symptoms on
himself repeatably and consequentially without him suffering of somatic incapacities or mental
disorders. The motivation for this behaviour is almost always obscure, this individuals with this
behavioural pattern have substantial abnormalities in personality and social skills. It is important
to mention that malingering is not on this category because, even if the behaviour of the patient is
the same, the motivation oh it is usually for external reasons like: juridical reasons, obtaining illicit
drugs or be excluded from military service. This category includes: hospital hopper syndrome,
Munchausen syndrome and wandering patient syndrome [6].
In DSM-5, FD are under the section of Somatic Symptoms and Related Disorders. Here, FD
include 2 different pathologies: FD imposed on self (Munchausen syndrome) and FD imposed on
another (Munchausen by proxy syndrome) [7]. The criteria of diagnose are basically the same for
ICD-10, but the difference is that Munchausen by proxy syndrome, in which the patient uses a
victim in order to seek attention, making harm or fabricate symptoms on the victim, not on self is
included in the diagnose category of child abuse (under the code T74.8) in ICD-10. In DSM-5,
Munchausen by proxy syndrome is a mental health problem of the patient, not the victim.
Nowadays, ICD-11 (the 11th edition) tend to regulate this difference between the guidelines
mentioned above because in this new edition FD contains only 2 entities: factious disorder imposed
on the self and factious disorder imposed on another (that are currently on DSM-5) [8], basically
removing FD from the old category “Other personality and behaviour disorders of the adult”.
In clinic, realistically it is very difficult to diagnose FD because there are no objective criteria.
People with FD tend to be expert at faking symptoms and usually have strong medical
knowledges and with every new episode they tend to use more complex strategies. Sometimes they
can fake a whole new identity just that the doctors cannot access previous medical records [9].
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That is why, the doctor can take into consideration that the real diagnose for a patient is a FD
when that person’s medical record are hard to find or don’t have logical course of action or the
person resist getting information from previous medical records. Also, when the symptoms that the
person presents or the course of the illness are abnormal or there are no objective criteria (like
inconsistent lab test result), FD could be the only explanation for that person. If the person is caught
in the act of lying or causing an injury then the clinician has a very strong argument for the
diagnose.
Case Report – Association Between Munchausen Syndrome (MS) and Munchausen by

Proxy Syndrome (Mps)
To understand and have a real imagine of what FD are we documented an unusual case of MS
and MpS association in the same family. This association between a MS on a young patient and
her mother with MpS presented on Infantile Neuropsychiatric Clinic from “Socola” Institute of
Psychiatry in March 2019 because after a long history of pediatric medical service abuse, the
clinicians from pediatric clinic calls social services to investigate this bizarre relationship between
the daughter and the mother. Their initial supposition was that the mother was abusing her
daughter, inflicting her numerous of symptoms in order to seek medical and social attention.
The person diagnosed with MS was a 13-year-old girl that had 34 presentation in the pediatric
service care in two weeks. The reason for this presentation varied from minor complains like
diffuse leg pains, or lack of vision accuracy to real injuries such as post-traumatic inflammation of
the joint, epileptic-like seizures, traumatism of the mouth, different skin alterations (scratches,
bruises). Every time the patient was investigates with full set of blood test. In some of the
presentation on the patients was conducted EEG’s, ophthalmological, neurological, orthopaedic
exams and even IRMs. None of the investigation could establish a real cause that could justify the
symptoms, except the post-traumatic lesions. Studying the evolution of this 34 pediatric care
presentations of the patient we observed that the first ones were for minor complains like: diffuse
leg pains or lack of vision accuracy, but because the doctors could not find anything wrong with
the patient that could justify that symptoms, the patient started accusing epileptic-like seizures,
fainting, acute pains and migraines, but also the doctors could not find a real cause for them.
Finally, the last presentation was for a various post-traumatic lesion in which the doctors could
see a real injury on the patient: traumatism of the mouth, joint inflammation, skin lesion like wide
extended bruises.
The pediatric doctors observed that every time that they told the mother that on her daughter
there is no clinic reasons for the symptoms, she would get angry, starting making a scandal and
demanding more test for her daughter. That is why they decided this could be a case of child abuse
and called social services.
Social services, as the law impose, brought the daughter to a psychiatric and psychologic
expertise in order to establish her mental status.
The psychiatric and psychologic exams showed that the patient was a teenage girl with an IQ of
124 that possess a large spectrum of medical information. Evaluating her emotional state, the only
abnormal thing that could be found was the tendency for emotional lability, but this could be seen
as normal reported to her age (she is 13 years old teenager). But we also find out that her father left
her and her mother when she was 5-6 years old because he went to become a surgeon in other
country. When she was speaking about her father, her behaviour was unstable: she had many
anxious breakdowns, and even if she was not expressing good feelings about him, the fact that she
believed he was an important doctor somewhere justified for her his actions.
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In the time she stayed at Infantile Neuropsychiatric Clinic she was once more somatic
investigated and the lab test, neurologic examination, EEG were with no modifications, and when
she found out that she is still not ill, she started producing on self-traumatic lesions like: scratches
on her leg that could justify her leg pains, she was self-harming her to get bruises, and this
behaviour was seen by the staff that was supervising her on many occasions. When she was asked
about this action, she every time denied them, telling the doctors and psychologist who interview
her that other kinds from the clinic, or just casual accidents (like falling off the stairs because of
her impaired vision) provoked the lesions. It is important to mention that on her time in the Clinic,
she didn’t have contact with her mother, and in one interview she told us that her mother, when she
was little, she went many times with her to the hospital, but she then didn’t understand why because
she didn’t have any pain or lesions.
Meanwhile, the investigation for child abuse on the mother was on, and when we have the
chance to speak with her, we found out that she also has strong resentments on her daughters’
father, and the assumptive medical problems of the daughter started after he left them. We asked
for medical records of the daughter from that period, but every time the mother founded a reason
not to bring them and she never told us a concrete diagnose that her daughter have received. We
could observe at her a strong obsession on the fact that her daughter is sick, that she will prove that
fact to all of us and also the judge and social services and for this situation the one who is
responsible is the father who abandoned them.
The real challenge in this case was that the first assumption of the examination team was indeed
that the mother committed psychical child abuse, but the fact that we saw the patient provoking on
herself different kind of lesions in absence of her mother, we started to see that the problem is with
both, and the mutual cause of them is to justify the implication and the trauma that her abandoning
father had produce. It is interesting to observe this mother-daughter bounding in which the mother
accepts harming her child, and the child gladly does that in the name of their trauma. But the social,
behavioural and health implication of that behaviour is that in the end, the child suffers physically
and emotionally and it could but his life in real danger.
Regarding all of this, and establish that the child does not have any real somatic problem or
psychological disorder, having proof that she was self-inducing psychical trauma and the
motivation for that is a deep emotional disruption we could put the diagnose of Munchausen
Syndrome, and because the mother, with no mental pathologies, encouraged this behaviour and
used her child in order to obtain medical attention, without having a material or social gain, but
having unresolved conflicts with her daughters father we could say that she suffers from
Munchausen by proxy Syndrome.
Profiling the Patients with FD
As we saw above, the difficulties that a clinician could come upon in diagnosing and managing
a FD case are on many levels because of the polymorphism of this pathologies. This is also
important because early detection could limit harm to patients.
In 2017, Callegari C et al., conducted a systematic review on FD based on clinical cases reported
worldwide [10]. The only exclusion criteria where cases by proxy, aged under 18 and articles that
were not presented in English. 577 reports were included in the review. Based on the results of this
metanalyses created the profile of the patient with FD: married female, at the age of 32.8 years.
Another aspect that this review shows is the fact that in 43,1% cases the patients had a
personality disorders and in 37,7% cases a depressive disorder, but at 39,5% cases psychiatric
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comorbidity was excluded. Somatic comorbidity was presented at 28.4% of the cases. But overall,
the majority of the cases didn’t have any other real somatic or psychiatric pathologies associations.
Another aspect that is worth mention is that, from all the cases analysed 35% of the patients had
a positive history for multiple surgical procedures. Stressful events in correlation with FD were
followed and the outcome was that: 20.2% of the patients show stressful or traumatic events, 14.6%
had physical or sexual abuses or neglect in childhood, 16.9% showed substance abuse, 10.7% had
conflicting and/or unstable interpersonal relationships, 7.2% reveal premature familial
bereavements, and maybe the most considering fact is that 13.4% presented a suicidal behaviour
[10].
Also, in 2017, Yates G et al., concentrated their attention on the Munchausen by proxy
syndrome and tried to profile the oppressors. They realized a review on the subject analysing a
sample of 796 case reports of MpS [11]. Their metanalyses showed that 97.6% of the cases were
women and 95.5% of them were mothers. 75.6% of them were married. The clinical characteristics
of them showed past or current depression in 14,4% of cases and personality disorder in 18.6% of
cases [11]. The report showed that 23.5% had history of obstetric complications and 30% of
childhood maltreatment [11]. The methods of abuse on the victim were fabrication by words in
45.9% of cases, simulation in 22.3% of cases, induction of symptoms on victim in 63.1% of cases,
fabrication that continued during hospitalization in 54.4% of the cases. The report also showed that
in 14.2% the victim collaborated with the oppressor [11].
Managing FD
For the healthcare professionals it is hard to face FD patients. Their tendency to be involved in
every step of medical process, constant complaints about the medical care or procedure and the
fact they usually report signs and symptoms that cannot be clinical objectified (pain, seizures,
fainting, suicidal behaviour) create for the clinician a real challenge in dealing with the patient.
Usually the evolution of this kind of patient doesn’t improve despite treatments and medical
procedures they receive. Anything that healthcare professions are trying to do in order to re-
establish the health balance of the patient is not enough. That is why, when clinicians delay the
diagnose of FD a chain reaction starts that involve unnecessary procedures, investigations, inter-
clinical consults and examinations, drug administrations.
What can we do in managing this kind of relation between a FD patient and medical system?
First of all, every clinician that has contact with the patient should have all the past medical
information on the patient that he could get. Secondly, it is important to collaborate with a medical
team in order to see the patient from every angle. Listening to the patient needs and complain could
make him more collaborative with the team because the clinician could discover the emotional
reasons behind the patient’s behaviour. Also, a psychiatrist and psychologist should be apart
because usually the pharmacological treatment of the underlying depression and anxiety is needed,
and, the most important, the managing of the emotional disruption should start with individualized
psychotherapy.
A very useful tool for the clinician is The Factitious Disorder Self-Assessment Scale (FDSAS)
that Lazzari et al developed in 2018 that has 17 items that the patient evaluates on a scale from 5
to 1 (5-almost always true; 1-almost never true) that can help in clarifying patient’s distress and
behavioural components of FD [12, 13, 14].
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Conclusions
Comparing the case, we documented and reported with literature review summarized in this two
important metanalyses presented above we can observe that the consistency of FD cannot be
ignored. Even if for the general practice it is hard to manage this patient, it is important to
understand how to do it and to accept the fact that FD are a real medical problem that involve nor
only abnormal behaviour, but also deep emotional impurities. Once we develop a complex, but
strong interprofessional collaboration we can reduce the hospital admission and unnecessarily
medical procedures and investigation for these patients and focus on the real solution that implies
psychiatric and psychotherapeutically managing.
Rising the awareness and trying to establish clear diagnose steps in order to bring the patient
with FD in his health and social balance.
Doctors tend to let FD as the last possible diagnose because the somatic symptoms are usually
a priority and mostly there is no time to see the whole picture of the patients complains, leading to
expansive medical procedures, costing the healthcare system important resources. That is why
protocol of diagnose and education of healthcare providers should be conducted. Only when a
proper diagnose is made it is possible to improve the outcome in the treatment.
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Neuropsychiatry (London) 2018 8(1): pp. 281-92.
10. Yates G et al., The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) – A systematic
review of 796 cases. Child Abuse& Neglect, 2017, 72: pp. 45-53.
11. Lazzari C et al., Unmasking and Managing Factitious Disorders in Primary and Secondary Care, CPQ
Medicine, 2018 3:4 pp. 1-10.
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Trends in the Treatment of Patients with Disorder Linked with

Alcohol and Associated Depressive Disorders
SARBU Fabiola1, TERPAN Mihai1*, CATANA Simona Cristina3,
CIUBARA Anamaria2
1 PhD student at “Dunarea de Jos” University, Faculty of Medicine and Pharmacy Strada Domnească nr. 47, Galați,
(ROMANIA)
2 PhD Hab. Prof. Dr. at “Dunarea de Jos” University, Faculty of Medicine and Pharmacy, Head of Department Psychiatry,
Primary Psychiatrist at Psychiatric Hospital “Elisabeta Doamna”, Galati, (ROMANIA)

3 Pharmacist, “Help Net” Pharmacy Galati (ROMANIA)
* Corresponding author: TERPAN Mihai
Email: terpan.mihai@yahoo.com
Abstract
Introduction
Romania ranks among the top 10 countries in the world and among the top 5 countries in Europe
on WHO (World Health Organization) drinking per capita. Alcohol consumption is often explained
by patients through an affective spectrum disorder (depression).
Objective
The retrospective study attempts to establish an association between the two conditions as well
as the percentage of associated antidepressant medication.
Method
Patients admitted to “Elisabeta Doamna” Hospital in Galaţi were selected during 2018 who
presented the double association between alcohol-related disorders and affective disorders
(depressive spectrum). For diagnosis of the ICD-10 (International Statistical Classification of
Diseases and Related Health Problems) criteria as well as HAM-D (Hamilton Rating Scale for
Depression), Audit psychometric tests were used. The evaluation of the association of
antidepressant medication with treatment was sought. Results. Out of a total of 12345 patients
admitted in 2018, 3386 had the diagnosis of alcohol-related disorders (27.43%) and 5596 (45.33%)
had affective disorders. A total of 2,386 patients (19.33%) experienced a double association of
alcohol-related disorders and affective disorders. Treatment with antidepressant medication was
associated with a total of 318 patients (13.33%). The most commonly used drugs were Tca
(tricyclic antidepressants) (29.2%), SSRI (specific Serotonin reuptake inhibitors) (23%, SNRI
(Serotonin-noradrenaline reabsorption inhibitors) (7%), others (24.8%), SARI (Serotonin
antagonist and reuptake inhibitors) (15.7%), NaSSA (Noradrenergic and specific serotonergic
antidepressants) (0.3%).
Conclusions
Affective disorders in the context of association with alcohol-related disorders require a closer
approach to increasing identification and an association with antidepressants at optimal dosages
for treatment.
Keywords: depression, alcohol, dual diagnosis
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Introduction
Drinking alcohol is a common thing in our society. While the majority of the population
consume alcohol without problems many people develop problems related to alcohol consumption.
Romania ranks among the top 10 countries in the world and among the top 5 countries in Europe
in alcohol consumption per capita according to WHO. Excessive consumption can lead to alcohol-
related mental disorders. Depression is a mental disorder with serious consequences on the person
but also through direct and indirect costs on the national and world economy.
The association between alcohol consumption and depressive disorder is complex involving
countless diagnostic and treatment problems. However, it is necessary to analyse the relationship
in order to be able to properly conduct the treatment of patients with such associated morbidity.
First, some alcoholic patients may develop a depressive disorder at any time in their lives but
without being able to establish a relationship with the consumption of alcohol. It is also known that
most patients who get over withdrawal develop a depressive disorder that eventually require
intervention therapeutic specialist with antidepressants. It is important to detect such an association
given the increasing frequency of hospitalizations of patients who associate alcohol with a disorder
from the spectrum of depressive as well as prognosis of severely of such associations.
The prevalence of depression morbidity and alcohol use disorders was demonstrated in a number
of researches [1-4]. Depression in a person with the consumption of alcohol can decrease the
judgment to resist consumption, and can sometimes lead to the use of alcohol to reduce depressive
symptoms [5, 6]. It is important to understand the significance of the association of depression and
consumption of alcohol, because this can explain why most cases recad after the treatment of
alcohol dependence [5, 6], and this association may explain why antidepressants have a benefit
moderately to the patients with depression and alcohol.
A number of studies have revealed the existence of a continuous association between alcohol
consumption disorders and major depressions [14, 15]. Studies suggest that a person often drinks
is more likely to develop major depression [11] [9]. A person can use alcohol to relieve himself
from depressive symptoms or reduce emotional stress. In addition, there is a reciprocity, the
consumption of alcohol increases the possibility of developing other disorders [2, 5] alcohol is used
as self-medication and possible there is a connection between alcohol consumption and resistance
to antidepressant treatment. People who use alcohol to relieve depressive symptoms and stress may
require treatment to achieve complete remission after alcohol use disorder.
Method
Data were collected between 1 January 2018 and 31 December 2018 in the Galati area. For
diagnosis, ICD-10 criteria (classification of mental and behavioural disorders) were used.
Depressive symptoms were measured using HAM-D psychometric tests (Hamilton Rating Scale
for Depression) and alcohol-related tests using the Audit test. Patients who met the criteria for
alcohol-related disorders in combination with the criteria for depressive disorders were included.
Demographic indices used were age, sex of participants and urban or rural provenance.
Depressive disorders selected according to the ICD-10 were: disorders of the spectrum of
depression (F32-F38), disorders that associate elements of depressive and affective (F41.2),
disorders of adaptation with elements of depressive or mixed (F43.2) and affective disorders with
elements of depressive with organic background (F06.3). In patients who met the double
combination, the antidepressant medication associated with the discharge was analysed.
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Data Analysis
The collected data was encoded, entered and stored in the computer. The data were analyzed
using SOFA Statistics (statistics, analysis, & reporting program) version 1.4.6 and JASPER Team
(2018). Jasper (Version 0.9) [computer software]. A logistic regression analysis was performed to
determine factors associated with the presence of depression.
Results
Of a total of 12345 patients admitted in 2018, 3386 had a diagnosis of alcohol-related disorders
(27.43%) and 5596 (45.33%) had Affective Disorders. A total of 2,386 patients (19.33%)
experienced double Association alcohol-related disorders and Affective Disorders.
The distribution of patients for the months of the year from January to December was as follows:
Month Frequency Percent Valid Percent Cumulative Percent

April 33 10.4% 10.4 10.4
August 27 8.5% 8.5 18.9
December 32 10.1% 10.1 28.9
February 19 6.0% 6.0 34.9
January 27 8.5% 8.5 43.4
July 24 7.5% 7.5 50.9
June 29 9.1% 9.1 60.1
May 24 7.5% 7.5 67.6
March 32 10.1% 10.1 77.7
November 25 7.9% 7.9 85.5
October 33 10.4% 10.4 95.9
September 13 4.1% 4.1 100.0
There is a maximum in March (10.1%), April (10.4%), October (10.4%), December (10.1%)
and a minimum in February (6.0%) and September (4.1%). Perhaps the lows are in the context of
the end of the winter holidays and before the new grape harvest. The maximum values are in
relation to the Easter and Christmas religious holidays as well as the new grape harvest.
Valid
GENDER Frequency Percent
Percent
f 73 23.0 23.0
m 245 77.0 77.0
Total 318 100.0
The distribution by gender shows a frequency significant gender male (77%) compared to
female (23%) and distribution on the environment of origin shows that those in urban areas (68.2%)
access more frequently the emergency services and hospital specialist the face of rural (31.8%).
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Environment Frequency Percent
rural 101 31.8
urban 217 68.2
Total 318 100.0
The most used diagnosis associated with disorders related to alcohol is F38 in 100 cases (31.4%)
and the lowest is F33 10 cases (3.1%).
Diagnosis Frequency Percent

f06.3 23 7.2
f32 53 16.7
f33 10 3.1
f34 31 9.7
f38 100 31.4
f41.2 55 17.3
f43.2 46 14.5
Total 318 100.0
Next in order, F41.2(17.3%), F32(16.7%), F43.2(14.5%), F34(9.7%) and F06.3(7.2%).
Valid 318
Mean 52.23
Std. Error of Mean 0.6956
Median 53.00
Std. Deviation 12.40
Kurtosis -0.2746
Minimum 18.00
Maximum 86.00
Age distribution shows an age of patients between 18 and 86 years with an average of 52.23
years and a deviation of ±12.40 years. The group of patients is past middle age, an explanation
could be the presence of other diseases associated with or diminishing the amount of alcohol
supported metabolic.
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As they notice the treatment of depressive disorders associated with disorders related to alcohol
consumption show a predominance of tricyclic antidepressants (29.2%), which is associated with
comorbidities depressive F38 (other disorders of mood depressive).
Other antidepressants (24.8%) from other categories are associated more frequently with
diagnosis F41.2 (Disorder mixed anxiety and depressive) and F43.2 (adjustment disorder 0.20
reaction depressive short, 0.21 reaction prolonged, 0.22 reaction mixed).
SSRI (serotonin reabsorption inhibitors) (23%), are more preferred in F32 (depressive episode),
F41.2 and F43.2.
SNRI (serotonin-noradrenaline reabsorption inhibitors) (7%) are preferred in F33 (recurrent
depressive disorder).
Conclusions
1) there is a tendency in the occurrence of depression after drinking ethyl alcohol and most
cases do not necessarily require treatment for depression.
2) it is important to monitor depression and evaluate it to determine the treatment needs during
post-alcohol recovery.
3) affective disorders in the context of the association with disorders related to alcohol requires
a more careful approach in order to increase the degree of identification as well as a
combination with antidepressants in optimal doses of treatment [16, 17].
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test” in Guidelines for Use in Primary Care, WHO/MSD/MSB/01.6, World Health Organization, Geneva,
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Involvement Screening Test (ASSIST): Guidelines for Use in Primary Care (Draft Version 1.1 for Field
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Peculiarities of Depressive Disorder in Elderly Patients
SARBU Fabiola1, CORBEANU Dan-Constantin2*, CIUBARA Anamaria3

1 PhD student at “Dunărea de Jos” University, Galați, (ROMANIA)
2 resident doctor, “Elisabeta Doamna” Psychiatry Hospital, Galați, (ROMANIA)
3 MD, Dr., Hab. Professor, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University, Head of Psychiatry Department,
Senior Psychiatrist “Elisabeta Doamna” Hospital, Galați, (ROMANIA)

* Corresponding authors: CORBEANU Dan-Constantin
Email: corbeanud@yahoo.com
Abstract
Introduction
Depression has been recognized as one of the top three disabling medical conditions of the
elderly people in the 21st century. Large-scale emigration, poverty, widespread corruption and the
rapid pace of technological changes worldwide are some of the main factors for a high prevalence
of depressive disorder among elderly people of Romania.
Aim
The aim of this reading is to find some particular areas of assessing depression in elderly people
of Romania, at the beginning of 21st century. Although well-known scales of assessment are very
good and useful, the increasing prevalence of depression sometimes calls for a deeper investigation.
Method
Widely-used scales (Hamilton Depression rating Scale, Montgomery-Åsberg Depression Rating
Scale, Geriatric Depression Scale, Patient Health Questionnaire) are compared and evaluated with
the purpose of covering a broader area of cultural characteristics of Romanian elderly people. These
peculiar characteristics are subject of historical, religious and anthropological assessment; the
intention is not to establish precise questions for patients, but to better assess the areas of cultural
background of old people. This proper understanding can improve communication and can
contribute to a better adherence to psychiatric medical treatments.
Conclusions
Although there are some classic scales used for assessing depression in old people, cultural
issues in Romania might be very important, too. Every specific geographical area and time frame
has some particular traits which must be taken into account. Given the risk of suicide in these old
patients, a prompt medical and psycho-therapeutic treatment must meet all the needs, (mis)beliefs
and feelings of the geriatric patient.
Keywords: depressive disorder, assessment, elderly people
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Introduction
Depression has been recognized as one of the top three disabling medical conditions of the
elderly people in the 21st century, all around the world. [7] This presentation tries to find typical
areas of characteristics for Romanian elderly people confronted with this disorder.
Elderly people have a higher risk of completed suicide than any other age group worldwide.
The main psychological factors associated with suicide in elderly people include psychiatric
illnesses, most notably depression, and certain personality traits. Physical factors include
neurological illnesses and malignancies. [9]
The effects of physical health factors on suicide in elderly people are generally mediated by
mental health factors. Social factors include social isolation and being divorced, widowed, or
single. Those who have attempted suicide are at high risk of a subsequent completed suicide.
Prospective cohort and retrospective case control studies indicate that affective disorder is a
powerful independent risk factor for suicide in elders. Other mental illnesses play less of a role.
Physical illness and functional impairment increase risk, but their influence appears to be
mediated by depression. Social ties and their disruption are significantly and independently
associated with risk for suicide in later life, relationships between which may be moderated by a
rigid, anxious, and obsessional personality style. Affective illness is a highly potent risk factor for
suicide in later life with clear implications for the design of prevention strategies. [10]
Large-scale emigration has mounted for increases levels of loneliness in villages and small
towns of Romania. Extreme poverty has driven away the younger generations; for more than 25
years, a large exodus of people to more industrialised countries has emptied the houses of this
Eastern European country.
emigration extreme poverty
corruption Technology
Widespread corruption seems to worsen the situation in the past few years; it’s been said that
the immigration from Romania is very similar, in terms of figures, to a country after a war. The
rapid pace of technological changes worldwide is another factor for a high prevalence of depressive
disorder among elderly people of Romania, but this fact is not a specific feature; while elderly
people value human interaction in the first place, newer generations have a taste for spending very
many hours in a virtual reality created by means of computer games, social media, television. All
these features have created a typology of the depressed old patient in Romania. The presentation
tries to get some solutions to a better communication with these patients, with the purpose of a
good compliance to the medical treatment and a higher rate of avoiding the suicide.
Aim
The aim of this reading is to find some particular areas of assessing depression in elderly people
of Romania, at the beginning of 21st century, together with an improvement in the confidence of
the patient in the prescribed treatment. Although well-known scales of assessment are very good
and useful, the increasing prevalence of depression sometimes calls for a deeper investigation.
They are widely-used and the scientific data used in academic papers must be subject of similar
and simple questions. They also are important for assessing the severity of depression. Very often,
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the depressed elderly patient wants to explain some of the causes of his disorder, but the classic
scales seem to offer very scarse feed-back in this matter. These scales display only the present state
of the patient at the time of the interview, but they entirely ignore the causes that inflicted the
depression.
Elderly people have a higher risk of completed suicide than any other age group worldwide.
Despite this, suicide in elderly people receives relatively little attention, with public health
measures, medical research, and media attention focusing on younger age groups. [9]
The dialogue with the patient must address the cause, because, otherwise, the elderly patient
may think the doctor hasn’t got a proper understanding of this disabilitating disease. Moreover, a
depressed patient very often lives in the past and has very few people to value his life experience.
This proper understanding can improve communication and can contribute to a better adherence
to psychiatric medical treatments. Having in mind the limited time of the clinician, the presentation
tries to show some areas of cultural and historical background of the patient, which may be a plus
in the level of confidence.
Method
Widely-used scales (Hamilton Depression rating Scale, Montgomery-Åsberg Depression Rating

Scale, Geriatric Depression Scale, Patient Health Questionnaire) are compared and evaluated with
the purpose of covering a broader area of cultural characteristics of Romanian elderly people. None
of these scales searches for the causes that inflicted the depression, but rather for assessing the
severity of the depression at a given moment of time. [4] These peculiar characteristics are subject
of historical, religious and anthropological assessment; the intention is not to establish precise
questions for patients, but to better assess the areas of cultural background of old people.
Economics
Art
(occupations)
Religion Politics
This proper understanding can improve communication and can contribute to a better adherence
to psychiatric medical treatments. Western societies may have a different background of depression
and suicide. A study in five English counties found that physical illness, interpersonal problems
and bereavement are commonly associated with suicide in older people, but financial,
accommodation, retirement and long- term bereavement-related problems may be more specific
risk factors. [11] By means of previous personal experience with these specific patients, and having
in mind a broader work of the psychotherapist with these patients, we proposed some good-to-
know issues which may be useful in treating the elderly patients with severe forms of depression,
which are at risk for suicide or for not taking the prescribed medication [12, 13, 14]. Although a
range of other factors in the society might also be of importance, it was concluded that restrictions
in access to dangerous means for suicide were likely to play an important role in reducing suicide
rates in Denmark, especially for women. At the selective level, there are several important risk
groups such as psychiatric patients, persons with alcohol and drug abuse, persons with newly
diagnosed severe physical illness, all who previously attempted suicide, and groups of homeless,
institutionalized, prisoners and other socially excluded persons. [15] Although restricted access to
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dangerous drugs and early identification of people at risk of suicide are good measures to be taken,
a proper communication with severe depressed people has an important role.
Conclusions
Depression combined with suicide are a special health issue, which calls for a great deal of
support and attention. Whereas it is extremely difficult to assess one’s intention to commit suicide,
elderly people often face depression. Although there are some very good classic scales used for
assessing depression in old people, this procedure is not enough to catch the trigger points of this
disorder. A dialogue with the patient, even though the patients are reluctant to speak, can be useful
in maintaining the patient’s confidence in the medical approach.
Cultural issues of Romanian elderly patients with depression might be very important in cases
of documented intention to commit suicide. Every specific geographical area and time frame of
such a patient has some particular traits which must be taken into account. Given the risk of suicide
in these old patients, a prompt medical and psycho-therapeutic treatment must meet all the needs,
(mis)beliefs and feelings of the geriatric patient.
REFERENCES
1. DSM 5, Editura Callisto, 2013

2. Greenberg, P. E., Fournier, A. A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The economic burden of
adults with major depressive disorder in the United States (2005 and 2010). Journal of Clinical Psychiatry,
76, pp. 155-162. doi: 10.4088/JCP.14m09298
3. ICD-10, Editura TREI, 2016.
4. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10 th edition, 2017.
5. Prelipceanu, Dan., Psihiatrie clinica, Ed. Medicală, 2018.
6. doi: https://doi.org/10.1136/bmj.d5219, Depression in old adults, BMJ, 2011.
7. https://www.cdc.gov/aging/mentalhealth/depression.htm, Depression is Not a Normal Part of Growing Older.
8. https://www.apa.org/pi/aging/resources/guides/depression, Depression and Suicide in Older Adults.
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC523116/ Recent developments: Suicide in older people.
10. https://www.ncbi.nlm.nih.gov/pubmed/12182926/ Risk factors for suicide in later life.
11. https://www.ncbi.nlm.nih.gov/pubmed/16734947 Life problems and physical illness as risk factors for
suicide in older people: a descriptive and case-control study.
15. https://www.ncbi.nlm.nih.gov/pubmed/18208680 Prevention of suicide and attempted suicide in Denmark.
Epidemiological studies of suicide and intervention studies in selected risk groups.
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Comparative Assessment of Community-Based Mental Health

Services (CBMH) in 4 Pilot and Non-Pilot Districts after the 1st
Phase of the Reform of Mental Health System in the Republic of
Moldova
Chihai Jana1*
1 Chihai Jana, PhD, (REPUBLIC OF MOLDOVA), Associate Professor, Psychiatry, Narcology and Medical Psychology
Department, “Nicolae Testemițanu” State University of Medicine and Pharmacy, Chișinău, Republic of Moldova; Senior Mental
Health Advisor for MENSANA Project, (REPUBLIC OF MOLDOVA)
* Corresponding author: Chihai Jana
Email: jana.chihai@usmf.md
Abstract
The paradigm for approaching the people with mental health problems has changed over the
past years worldwide in the context of the World Health Organization (WHO) recommendations
and of the provisions of the United Nations Convention on the Rights of Persons with Disabilities
(CRPD), the patient’s pathway through the healthcare system being the following: family, social
services – family doctor – community mental health centres – district hospitals – specialized
psychiatric hospitals (the tertiary level) – community mental health centres. A countrywide reform
of mental health services was launched in 2014 in the Republic of Moldova within “MENSANA –
Support for the Reform of Mental Health Services in the Republic of Moldova” Project which was
initiated to pilot a new model of community mental health services. The comprehensive assessment
of the newly established mental health services after 4 years of reform of the mental health system
in 4 pilot and 4 non-pilot districts included such criteria as recovery-oriented care, home visits, the
referral system, work of the multidisciplinary team and management, and it gave us the opportunity
to check if the model proposed for implementation in the Republic of Moldova is effective.
Keywords: Community-based mental health services, community mental health centre
Introduction
In 2014, was launched “MENSANA – Support for the Reform of Mental Health Services in the
Republic of Moldova” Project, financed by the Swiss Agency for Development and Cooperation
and implemented by TRIMBOS Institute of Mental Health and Addiction. MENSANA is in line
with the reforming needs established by the Ministry of Health, Labour and Social Projection of
the Republic of Moldova (MHLSP) [1, 2]. The first phase of the project covered the period from
August 2014 to July 2018. Within MENSANA, was undertaken the decentralization of mental
health services and 4 model community mental health centres (CMHCs) were set up in the districts
of Cahul, Cimislia, Orhei and Soroca, according to the European standards, with all indispensable
organizational components, able to respond to the multidisciplinary needs of the people with mental
health disorders at the community level. The model of community mental health services developed
in these districts will be scaled-up at the national level [3, 4].
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The process of development of community mental health services started as of 1st of September
2014 by the establishment of a CMHC network at the national level (in municipalities and in each
second-level administrative-territorial unit). 39 CMHCs (6 in municipalities, 33 in districts,
contracted by the NHIC) were set up and contracted by the National Health Insurance Company
(NHIC).
The community centres are meant to provide people with mental health problems with
consultative healthcare, psychosocial recovery services, support and mediation, etc. The
development of the CMHC network favours the deinstitutionalization process by reducing the flow
of patients to the psychiatric hospitals and increasing the number of requests of community services
[5, 6].
CMHCs were established within primary healthcare institutions at the district and municipal
level, what contributes to the integration of mental health services into primary care, the early
detection of the mental pathology and to ensuring the continuity of treatment [7, 8].
Over the past 4 years, 100% of mental health professionals nationwide, as well as 100% of
family doctors and 30% of family doctors’ nurses in the pilot-districts have been trained in
community psychiatry within MENSANA Project. 4 national clinical guidelines in the field of
mental health, with standardized cards for family doctors, have been updated to facilitate the
management of mental health problems at the primary healthcare level, as recommended by the
WHO [9, 10, 11, 12].
The system of provision of mental health assistance in the Republic of Moldova is governed by
regulatory acts which are currently in line with the international requirements in order to provide
accessible and qualitative services to the users [13, 14, 15].
In the context of the scale-up of the new model of care, it was necessary to conduct a thorough
assessment of mental health services (a clinical audit) at the community level, by the means of a
comparative study of the work of CMHCs and PHC facilities in the 4 pilot-districts and 4 non-pilot
districts.
The aim of the audit is the comprehensive evaluation of mental health services in the four pilot-
districts (Cahul, Cimislia, Orhei and Soroca) and in 4 non-pilot districts (Hincesti, Ungheni, Edinet
and Leova).
The assessment was done based on such criteria as recovery-oriented care, home visits, referral
system, functionality of the multidisciplinary team and management.
Audit’s Objectives
1. Evaluation of CMHC infrastructure

2. Human resources evaluation – the composition of the multidisciplinary CMHC team
3. Evaluation of the working methodology, the accuracy of keeping the registries by the
CMHCs
4. The compliance of CMHC information included in form 36A with the registries, medical
cards and patient files
5. Evaluation of the level of user satisfaction with the services provided by the CMHCs
6. Evaluation of the integrated mental health services within PHC
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Design of the Assessment
A methodology comprised of several instruments was developed to evaluate the correspondence

of CMHCs to the Government Decision 55 from 30.0.2012 on the Framework Regulation of the
Community Mental Health Center and Quality Standards and based on fidelity scale of FACT.
The fidelity scale of the FACT model was included to describe the elements of the new model
of care including: multidisciplinary team structure – what disciplines are represented and for
how many hours a day; size of load case – what is the client –clinician ratio; share of case load –
does the team work as a group and not as individual clinicians and how many team members do
clients have contact with; daily FACT-board meetings – how many times a week the team have
a FACT-board meeting; treatment plan meeting with client – are patients involved in the
treatment plan meetings; frequency of contacts with clients – how often are patients at the FACT
board seen; team cohesion – how often does the team meet discuss team related issues; team
communication – does the team have a secure communication strategy for urgent and non-urgent
patient related issues.
For the purpose of evaluating the correspondence to the quality standards expected from
CMHCs a series of questionnaires for auto evaluation and checklists for interviews were developed
in parallel.
Inclusion criteria
- 4 pilot CMHCs developed by MENSANA project:

- 4 CMHCs developed independently and had not support by the project.
Criteria of inclusion on non-pilot CMHCs:

- the same no. of population covered
- the same geographical area as the pilot CMHCs
- similar incidence and prevalence as the pilot CMHCs
The assessment’s tools:
Major components were included in the evaluation:

1. Questionnaire – self-evaluation of infrastructure, where the name and founding date of the
CMHC was included, the date of contracting from the National Medical Insurance
Company, description of offices including surface in m2, also working hours, development
and implementation of center action plan and contact information was part of the
questionnaire.
2. Questionnaire – self-evaluation of the CMHC comprised of information on the coverage
area (population covered by the CMHC), full name of the center, date of founding,
founders, years of functioning, work schedule, work agenda if particular for some activities,
team componence and budget distributed by expenditure categories.
3. Questionnaire – self-evaluation of each team member with the name, age, position, working
schedule, studies, work experience including within the mental health system,
responsibilities and description on one day of work.
4. Interview criteria for site visit interview within the CMHC applied by experts in the
following areas: for CMHCs: recovery-oriented care, home visits, referral system,
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multidisciplinary team functioning, management; for Primary Health Care (PHC):

Evaluation of skills, referral system.
5. Questionnaire for evaluation of clients applied by experts within CMHC and in-home visits.
The questions covered gender, age, studies, family status, living conditions, age of
diagnosis, age of first hospitalization, number of hospitalizations within a year, increase of
hospitalizations, remission period, treatment in home conditions, disability degree, usage
of psychiatric services within the CMHC, monthly frequency of service usage, home visits
of CMHC team and frequency, pharmaceutical and nonpharmaceutical treatment used,
counselling received by the social care specialist form the center and purpose of
counselling, occupations in home conditions, and other occupations.
6. Questionnaire of self-evaluation of mental health services provided by family doctors
included name, age, gender, studies, work experience and in particular within the PHC,
number of patients diagnosed with depression, anxiety during one month, how patients are
recorded, rate of treatment prescribed by family doctors out of the total number
diagnosticated, type of medicine prescribed, usage of clinical protocols, referral system and
documentation, working procedure after referral and monitoring system used.
Period of evaluation was January-March 2018: The self-evaluation questionnaires were sent
together with the evaluation schedule through the ministerial ordinance no. 573 from 07. 05.2018
by the MHLSP to all evaluated structures with the request to ensure the access of evaluators to the
CMHC and PHC as well as fill in end send prior to the evaluation visit the filled auto-evaluation
questionnaires.
Conclusions related to CMHCs
With the implementation of the new model of care and the launch of the Project for the reform
of mental health services, the pilot CMHCs benefited, under the project, from more support
compared to non-pilot CMHCs.
Below are listed the major points of the identified differences:

• The pilot CMHCs were better equipped than non-pilot CMHCs, both in terms of premises
and computer equipment. A better composition of the multidisciplinary teams was also
noticed and the compliance with the requirements of both chapters of GD 55.
• There is a difference between the pilot and non-pilot CMHCs in terms of available budgets
allocated by the CNAM for service provision. The discrepancies between the composition
of the multidisciplinary teams and the spaces managed by the CMHC have led to
oscillations in terms of distribution of the budget by categories of expenditures, which also
differs from one CMHC to another.
• The requirement for having a social assistance professional in the multidisciplinary team is
solely respected by the pilot CMHCs, however, the clarity of the social assistant’s tasks is
at the concept level.
• There is still a shortage of human resources within the community mental health system.
Most CMHCs face a lack of professionals, the situation being particularly serious in non-
pilot districts.
• The capability of the multidisciplinary team needs improvements. The capacity to establish
a primary diagnosis in CMHCs is deficient. The psychiatrists in 2 pilot-districts and 2 non-
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pilot districts follow the concept of the new model of care and are responsible for
establishing the diagnosis. 4 CMHCs use to establish a presumptive diagnosis and to refer
the patients to a CPH for a final diagnosis. Both the psychiatrists, the clinical psychologists
and the social assistants and nurses need training for capacity building.
• The shortage of professionals determines a one-dimensional approach to treatment instead
of the multidisciplinary approach required by the new model of care, the services being
mostly focused on medical treatment, especially in the non-pilot CMHCs.
• In the pilot CMHCs, treatment plans are set up with the patient’s involvement and with
his/her informed consent, while in non-pilot CMHCs the informed consent is either missing
or contradictory to bioethical rules, the treatment being unilaterally established by the
CMHC psychiatrist or by the CPH and further continued within the community mental
health centre.
• National clinical guidelines are used in diagnosis and treatment, what demonstrates a
common approach to treating mental health disorders.
• Home visits are much more common in the pilot CMHCs, being properly documented and
confirmed by the questioned patients. Non-pilot CMHCs make sporadic visits.
• The collaboration between different district authorities, such as the social assistance
directorate and the police inspectorate is better in pilot CMHCs, while the collaboration
with PHC is good in all CMHCs subject to evaluation, with a well-structured referral
system.
• The pilot CMHCs plan and structure their activities in line with the new model of care. The
non-pilot CMHCs hold meetings only when necessary.
• Documenting of the care process is better done in pilot CMHCs, registers, medical cards
and case files being accurately kept. The situation in non-pilot CMHCs is different, the
registers established by the ministry are either not used, or case files are missing, home
visits are not documented.
• The evaluated users reported a decrease in the number of hospitalizations and the increase
of the remission period, what proves the efficiency of the community-based treatment.
Recommendations related to CMHCs
• Endow the CMHCs according to GD 55 on 30.01.2012, provide the multidisciplinary teams

with staff.
• Determine more clearly the role and the responsibilities of the social assistant within the
multidisciplinary team.
• Document more thoroughly the interventions in the patient’s file and develop the treatment
plan with the patient’s involvement.
• Train certain members of the multidisciplinary team to provide services following the new
model of community-based care. Implement the multidisciplinary approach to treatment.
• Institutionalize the national clinical guidelines.
• Conduct the monitoring of the patients after the discharge and establish a general system of
referral for all structures involved at the community level and for the tertiary services.
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Conclusions related to PHC facilities
• Diagnosis and treatment of mild and moderate mental health disorders is done in all districts
subject to the evaluation.
• In most non-pilot districts, the diagnosis established by the family doctor is presumptive
and a referral to the CMHC is made for further confirmation.
• The family doctor prescribes medication for mental disorders, if the treatment was
established by the psychiatrist in the CMHC.
• Clinical guidelines are not institutionalized in all PHC facilities subject to evaluation or, if
institutionalization was done, the treatment is not always compliant with the standardized
cards from the guidelines, what leads to a non-uniform approach to the treatment of mild
and moderate mental disorders in PHC.
• The referral between PHC facilities and CMHCs is done based on 027/e form, but the
patient’s monitoring requires improvement.
• Screening for early detection among the somatic patients is only carried out if the family
doctor suspects any problem, therefore mild mental disorders are undiagnosed, letting thus
them turn into chronic or aggravate.
Recommendations related to PHC facilities
• Recommendations for all PHC facilities subject to the evaluation – conduct the early
screening of all primary patients with somatic diseases and include the audit of health
services in the internal health audit plan of the health centre.
• Institutionalize the clinical guidelines and provide training on how to use them in the
process of diagnosing and treating mental health disorders, if such a process has not started
yet.
• Conduct a clear monitoring of the patient throughout the pathway of care.
• Although the PHC staff in the pilot-districts have been trained, the PHC facilities in the
pilot-districts do not differ significantly from the non-pilot districts, therefore the
recommendations are generally valid.
Table of Abbreviations
Full Name Abbreviation
Ministry of Health, Labour and Social Projection of the Republic of Moldova MHLSP
National Health Insurance Company NHIC
Word Health Organization WHO
Comprehensive evaluation of mental health services Clinical audit
Community-Based Mental Health model CBMH
Community Mental Health Centre CMHC
Primary health care PHC
Clinical Psychiatric Hospital CPH
Referral form – extract F 027/e
Flexible Assertive Community Treatment FACT
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REFERENCES
1. https://apps.who.int/iris/bitstream/handle/10665/310981/WHO-MSD-19.1-eng.pdf?ua=1
2. https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-
disabilities.html
3. Petrea, I. (2012). Mental health in former soviet countries: From past legacies to modern practices. Public
Health Reviews, 34(2), 1. doi:10.1007/BF03391673
4. http://trimbos.md/proiectul-moldo-elvetian-mensana-va-facilita-reformarea-serviciilor-comunitare-de-
sanatate-mintala-la-nivel-national/
5. Saraceno, B., van Ommeren, M., Batniji, R., Cohen, A., Gureje, O., Mahoney, J., Underhill, C. (2007). Global
mental health 5: Barriers to improvement of mental health services in low-income and middle-income
countries. The Lancet, 370(9593), p. 1164.
6. Chisholm, D., Flisher, A. J., Lund, C., Patel, V., Saxena, S., Thornicroft, G., & Tomlinson, M. (2007). Global
mental health 6: Scale up services for mental disorders: A call for action. The Lancet, 370(9594), p. 1241.
7. Pathare, S., & Shields, L. S. (2012). Supported decision-making for persons with mental illness: A review.
Public Health Reviews, 34(2), 1. doi:10.1007/BF03391683
8. Thornicroft, G. (2011). Community mental health. GB: Wiley-Blackwell.
9. Thornicroft, G., Tansella, M., & Law, A. (2008). Steps, challenges and lessons in developing community
mental health care. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 7(2), pp.
87-92. doi:10.1002/j.2051-5545. 2008.tb00161.x
10. Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive community treatment for people
with severe mental illness: Critical ingredients and impact on patients. Cham: Adis International.
doi:10.2165/00115677-200109030-00003
11. https://www.napha.no/multimedia/4519/Fidelity-scale-FACTS-English-version-2010.pdf
12. Slade, M., Thornicroft, G., Loftus, L., Phenan, M., & Wykes, T. (1999). CAN: Camber well assessments of
need. London (GB): Gaskell.
13. Wiley-Exley, E. (2007). Evaluations of community mental health care in low- and middle-income countries:
A 10-year review of the literature. Social Science & Medicine, 64(6), pp. 1231-1241. doi:
10.1016/j.socscimed.2006.11.009
14. http://lex.justice.md/index.php?action=view&view=doc&lang=1&id=342072
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Autism Spectrum Disorders (ASD) and Rare Genetic Diseases in the

Republic of Moldova: The Needs of Children with ASD and Genetic
Diseases and of their Parents/Caretakers for Medical, Social and
Educational Services
CHIHAI Jana1*, ADEOLA Cornelia2, BOLOGAN Alina3, COSULEAN Radislav4

1 Chihai Jana, PhD, Associate Professor, Psychiatry, Narcology and Medical Psychology Department, “Nicolae Testemițanu”
State University of Medicine and Pharmacy, Chișinău, Republic of Moldova; Senior Mental Health Advisor for MENSANA
Project, (REPUBLIC OF MOLDOVA)
2 Adeola Cornelia, clinical psychologist PA SOMATO, (REPUBLIC OF MOLDOVA)
3 Bologan Alina, PhD student, Psychiatry, Narcology and Medical Psychology Department, “Nicolae Testemițanu” State
University of Medicine and Pharmacy, Chișinău, (REPUBLIC OF MOLDOVA)

4 Cosulean Radislav, clinical psychologist PA SOMATO, (REPUBLIC OF MOLDOVA)
* Corresponding author: CHIHAI Jana
Emails: jana.chihai@usmf.md
Abstract
The aetiology of Autism Spectrum Disorders (ASD) is complex and multifactorial, and the
specialised literature identifies from genetic to environmental factors. According to Davis III, TE,
White, SW, Ollendick, TH (2014), more and more people have been diagnosed with autism
spectrum disorders over the past 20 years. The general problems caused by the autism spectrum
disorders and their social impact require that every human element of the system that works
towards the development or the recovery of a child with ASD (parent, educator, various specialised
therapists, doctors, etc.) should be aware of the possible obstacles they can encounter during the
recovery-integration process. To understand the needs of the parents/carers of children with ASD
and rare genetic diseases, this research aimed at assessing their needs in the medical, educational
and social fields and, after the assessment, recommendations were formulated to respond to the
needs of parents of children with ASD and genetic disorders.
Keywords: Autism spectrum disorders, rare genetic disorders, parents’ needs, medical, social, educational services, etc.
Introduction
On 26-27 November 2010, the Republic of Moldova adopted the European Declaration on the
Health of Children and Young People with Intellectual Disabilities and their Families “Better
Health, Better Life: Children and Young People with Intellectual Disabilities and Their Families”,
thus accepting a new conceptual approach to mental health issues and intellectual disabilities [1,
2]. People with ASD are still classified in the field of mental health and make up an important part
of healthcare, in general, and of mental healthcare, in particular. Mental health is one of the
priorities of the health system in the Republic of Moldova, as a result of joining the Helsinki Mental
Health Declaration as of 12-15 January 2005, along with the member states of the European
Community and in line with the obvious trend towards the European values [3, 4]. According to
WHO statistics, the number of children with ASD is increasing, with one child with autism in 60
new-borns. Asian and European studies have identified a 1% incidence, and in the USA, there is 1
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case per 68 births. The prevalence has increased by 6-15% every year from 2002 to 2010. At the
same time, it was found out that the cost of lifelong care could be reduced by 2/3 due to early
diagnosis and intervention. It has also been estimated that nearly half (46%) of children with ASD
have the chance to develop intellectual skills above the average [5, 6]. In Romania, there are 7800
children diagnosed with ASD, according to the official data.
Families of children with ASD usually have to change their daily routines, lifestyle or even their
view of life, the child’s diagnosis becoming a diagnosis of the family as a result of labelling [7, 8].
In such a situation, parents of children with ASD have little chance of talking to other parents.
Opening a channel for communication between specialists and parents could prevent the
situations when “the negative message reaches the parents and makes them subsequently feel even
more lonely, isolated and without any support” (Peeters, T., 2009). In the light of the idea of the
previously quoted author, we can state, in line with B. Bernstein (2000), that therapeutic and
educational practices are a fundamental social context in which a subculture arises, if we look at
people with ASD from this perspective [9, 10, 11, 12]. The blasé acceptance of the minority group
status and of the minority culture by the families of people with autism spectrum disorders is not a
solution for overcoming the marginalization, but rather its accentuation [13, 14, 15, 16].
The purpose of this survey is to assess the needs of children with ASD and rare genetic diseases,
and of their parents/carers with a view to change the policy documents in this field.
Objective 1:
Identify the needs for services for children with ASD and rare genetic diseases and of their
parents and carers in the medical, education and social fields.
Objective 2:
Make recommendations on how to address the needs of children with ASD and rare genetic
diseases, and of their parents and carers.
Survey Design and Methodology
The study includes a simultaneous assessment of the members of the Federation for Rights and
Resources of People with Autism Spectrum Disorders in the Republic of Moldova (FEDRA),
consisting of families in which children with ASD are raised and educated. Thus, a demographic,
morbidity and psychosocial individual survey will be conducted for each person. The survey will
be performed using a sociological questionnaire. It will involve parents of children with ASD.
In order to have a comprehensive assessment, with the further purpose to make a clear list of
needs, a questionnaire will be used to assess the following dimensions: services in healthcare field;
services in the field of education; services in the social field. The assessment questionnaire includes
demographic data, as well as questions to assess the needs for various services.
A number of methods for data collection and analysis will be used in the survey:
• Analysis of documents: studies, reports, statistics on the situation of autism spectrum
disorders in the world and in Moldova. Activity and research reports submitted by various
entities (in particular, NGOs from Romania and Moldova) will be analysed, along with
legislative documents, websites of national and international NGOs.
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• Sociological survey1, using a questionnaire, on a convenience sample of at least 40

respondents – parents/carers who raise and educate children with ASD throughout the
Republic of Moldova, in both the rural and the urban areas. The questionnaires were applied
at FEDRA2 office. The instrument was selected based on the following criteria: sensitivity
and specificity values, availability in Romanian language, access to the instrument and to
training on how to use it. Parents/carers questioned or interviewed were informed of their
voluntary participation in the survey, of the anonymity and confidentiality of the data
collected. Calculation of the sampling is done based on the minimum number of participants
required, taking into account the estimated number of children with ASD in Moldova, i.e.,
10% of 414 children with ASD in 2017.
Inclusion criteria: willingness to participate in the survey; signing the informed consent; aged
over 18; has a child with ASD and rare genetic diseases.
Exclusion criteria: unwillingness to participate in the survey; does not sign the informed
consent; aged below 18; does not have any child/children with autism; any person unable to give
an informed consent; any person in a terminal medical condition which reduces the ability to give
an interview.
Research Outcomes
Situational analysis in the field of ASD and rare genetic diseases

According to the data submitted by the National Public Health Agency, the specialists, including
the Community Mental Health Centres working under the primary public healthcare institutions,
have provided supervision: in 2015 – to 277 children; in 2016 – to 349 children; in 2017 – to 414
children; in 2018 – to 523 children.
Based on data available in the medical statistical reports, it can be estimated that the incidence
of psychological development disorders, which include ASD according to ICD-10, was estimated
to 246 people, including 205 children, in 2017, and the prevalence reached 1 422 cases, including
299 children. The situation of children with rare genetic diseases is illustrated in Chart 1.
Chart 1. Prevalence of rare genetic diseases in Moldova in 2017

Disease No. of cases registered by the Centre for Prevalence of the disease
Reproductive Health and Medical Genetics, among the population
Moldova
Phenylketonuria 107 patients/100 families 1:3-30.000
Wilson’s disease 73 1:25.000
Cornelia de Lange syndrome 7 1: 10000 1: 10000
Williams syndrome 4 1: 10 000
Prader-Willy syndrome 7 1: 10000 1: 20 000
Rett syndrome 8 1: 15000-20000 girls
X-fragile syndrome 2 1:2 000 men
Rare structural chromosomal 40
abnormalities
1 https://interventiepsihoeducationala.blogspot.com/2017/01/ghiduri-despre-
autism.html?m=1&fbclid=IwAR3Inexa95GjDpsRBI0VnAtuH9irLTLyDL5IVNrDQBP1YTh6nhCs6muVRm0
2
http://autismmap.md/despre-fedra/
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After all Community Mental Health Centres (CMHCs) completed a questionnaire about the
diagnoses with symptoms of the autism spectrum, which are not officially established as an autism
diagnosis, a number that is 2.5 times higher than the official statistics came out. These data for the
population of children can be seen in Chart 2, and for the adult population – in Chart 3.
Chart 2. Diagnostics that may hide ASD or other rare genetic diseases in the population of children – data collected
from district CMHCs and specialized NGOs in the Republic of Moldova (2018)
Chart 3. Diagnostics that may hide ASD or other rare genetic diseases in the adult population – data collected from
the district CMHCs and specialized NGOs in the Republic of Moldova (2018)
Outcomes of the Social Survey
Parents of children with ASD aged between 24 months to 16 years gave the following answers:
- State services the respondents benefited from: practically 95% answered – none state
services in country and about 5% of parents mentioned about recovery center, supervision
by a psychiatrist, medical prescription by neurologist and treatment with nootropics.
- specialists who were able to diagnose ASD: a psychiatrist, a neurologist, a specialist in the
private system or a private medical service, a paediatrician, a parent, a speech therapist;
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- 6% of the respondents’ children do not attend any educational institution;

- only 2% of children have a case manager appointed by the social system.
Findings and barriers to the development of this field reported by parents: lack of certain
categories of specialists; insufficient collaboration; shortage of diagnostic centres and accessible
support services; insufficient periodical assessments; lack of protocols and guidelines for the
monitoring of patients with rare diseases; shortage of social services; no official statistical surveys;
most educational units remain inaccessible to children and young people with different types of
disabilities and special educational needs, including preschool children.
At the level of early education, the process has not been subject to a systemic approach yet. The
mechanism for the operation of inclusive education services and their financing has not been
approved yet.
Recommendations
- Develop a scientific-practical institutional framework in the field of mental health and

genetic diseases at the national level as referral, resource and coordination institutions;
- Develop the national registry of ASD and rare genetic diseases;
- Identify a group of rare diseases to be subject to molecular testing in the Republic of
Moldova;
- Develop specialized medical-social mental health services for children with ASD and rare
genetic diseases;
- Undertake measures to ensure the access of the medical personnel to specific training,
develop the skills and the capability of primary healthcare professionals on early diagnosis
and referral of children with clinical signs of ASD and/or rare genetic diseases to
specialized services;
- Mandatory implementation and use by family doctors and nurses of the standardized tools
for early detection of ASD and rare genetic diseases;
- Strength the laboratory of cytogenetics, molecular genetics;
- Provide competent genetic counselling services for the population;
- Prenatal diagnosis of the families at risk of pregnancy with a foetus with a rare disease,
inclusion in the list of genetic diseases;
- Define/approve an applicable model for the inclusion of children with disabilities in early
education institutions in order to secure their right to education;
- Constant monitoring of the effective access of children with SEN to inclusive education
services at the local level;
- Develop and approve the requirements for the endowment of kindergartens and schools
with technologies, equipment, alternative communication systems, etc. to support the
inclusion of children with SEN;
- Assess how schools use the financial resources allocated for inclusive education;
- Include ASD modules in the curriculum of higher education and specialized secondary
education institutions (healthcare, social, psychology, psycho-pedagogy fields);
- Develop/improve the professional skills of family doctors, social assistance professionals,
teachers, support teachers, coordinators of multidisciplinary teams in the field of social
inclusion and inclusive education;
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- Supplement the curriculum of higher education institutions for educators and teachers with
courses in the field of communication and inclusion of children with disabilities;
- Individualise the required resources at the national level, depending on the needs and
standard cost per user of health, social and education services;
- Allocate financial resources for the provision of healthcare, medical-social and educational
institutions with specialized equipment for the assistance to children with autism spectrum
disorders and rare genetic diseases.
REFERENCES
1. Davis Iii, Thompson E., White, Susan W., Ollendick, Thomas H. (Eds.), Handbook of Autism and Anxiety
(2014), ISBN 978-3-319-06796-4: pp. 9-13.
2. Grant WB, Soles CM. Epidemiologic evidence supporting the role of maternal vitamin D deficiency as a risk
factor for the development of infantile autism. Dermato-endocrinology. 2009; 1: pp. 223-8. [PMC free article]
[PubMed]
3. www.autisminfantil.ro
4. Barnby G, Abbott A, Sykes N, Morris A, Weeks DE, Mott R et al. (2005). Candidate-gene screening and
association analysis at the autism susceptibility locus on chromosome 16p: evidence of association at
GRIN2A and ABAT. Am J Hum Genet;76(6): pp. 950-966.
5. Bertrand, J., Mars, A., Boyle, C., Bove, F., Yeargin-Allsopp, M., & Decoufle, P. (2001). Prevalence of autism
in a United States population: The Brick Township, New Jersey, investigation. Paediatrics, 108(5), pp. 1155-
61.
6. www.autismspeaks.org
7. Bopp-Limoge C., Pegliasco M., Morgenthaler L., Pascal V., (2010), Etayer les relations parents-enfants en
groupe de jeux quand l’enfant souffre d’autisme ou de troubles envahissants du de´veloppement, Annales
Me´ dico-Psychologiques 168 (2010) pp. 752-758.
8. Cappe E., Wolff M., Bobet R., Adrien J-L., (2012), Étude de la qualité de vie et des processus d’ajustement
des parents’ d’un enfant ayant un trouble autistique ou un syndrome d’Asperger: effet de plusieurs variables
socio-biographiques parentales et caractéristiques liées à l’enfant, L’évolution psychiatrique 77 (2012) pp.
181-199.
9. Chamak, B., (2008), Autism and social movements: French parents’ associations and international autistic
individuals’, organisations, in: Sociology of Health & Illness Vol. 30 No. 1 2008 ISSN 0141-9889, pp. 76-96
doi: 10.1111/j.1467-9566.2007. 01053.x
10. Gaspar de Alba M. J., Bodfish J. W., (2011), Addressing parental concerns at the initial diagnosis of an autism
spectrum disorder, Research in Autism Spectrum Disorders 5 (2011) 633-639.
11. Gillberg, C. (1991). Outcome in autism and autistic-like conditions. J Am Acad Child Adolesc Psychiatry, 30,
pp. 375-382.
12. Gillberg, C. (1998). Asperger syndrome and high-functioning autism. The British journal of psychiatry, 172,
pp. 200-209.
13. Van Leeuwen, K., Boonen, H., Lambrechts, G., et al., (2011), Parenting behaviour among parents of children
with autism spectrum disorder, Research in Autism Spectrum Disorders 5 (2011) pp. 1143-1152.
14. http://www.autism-aita.ro
15. http://www.autismsciencefoundation.org/what-is-autism/how-common-isautism
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Complications of Hips Hemiarthroplasty at Pacient with Dementia
VLAD Bradeanu Andrei1, PASCU Loredana2, CIUBARA Alexandru Bogdan2,

VOICU Dragos Cristian2, CIUBARA Anamaria2
1 PhD Student University “Dunarea de Jos” Galati, (ROMANIA)
2 University “Dunarea de Jos” Galati, (ROMANIA)
Abstract
Age is one of the most important parameters influencing the occurrence of hip fractures in
patients over the age of 65 but also their mental state is a decisive factor. Older adults have eight
times higher risk of dying of a hip fracture if we compared to those people without a hip fracture.
The risk of die it’s very high in the first three months but still continuing in first ten years. High
incidence of hips fracture and dementia in the world wide include: Europe and Middle East part of
Europe, South America, Canada, United States and Asia. There is a very high probability that
patients with hip fractures and dementia to developed delirium that will result a longer
hospitalizations and poor mobility.
Death is not a common complication of hip arthroplasty, under 1% patients in United States
died, but in the first 90 days postoperative mortality it is a little bit higher than 1%. In otherwise
after revision surgery the percent is higher.
The most common complications of hip hemiarthroplasty that can be avoided by the surgeon
are: dislocation (posterior approach),and infection (the most common are Gram-positive
Staphylococcus aureus – MRSA and Gram-negative bacillus) , in one year the mortality it will be
over than half at patient with deep infection and approximately at 65% at pacient with dislocation
prosthesis in 6 months but also depends by type of prosthesis: Monoblock (Austin Moore) or
bipolar, cemented or uncemented. Other patient-related complications in the order in which they
appear are: pulmonary embolism, hematoma formation, unusual ossification, thromboembolism,
nerve injury, fracture (periprosthetic). In patients who are receiving antiplatelet, anti-inflammatory
or anticoagulant therapy, it is necessary to stop the preoperative medication and to perform
intraoperative haemostasis. During surgery, surgeon can damage obturator vessels, perforating
branch of femoral is and injury iliac vessels when drilling medial acetabular wall. In the last two
decades thromboembolism has been prevented by physical therapy and socks with gradual
compression. Depending on the type of surgeon’s preferred type of surgeon, the following nerves
may be injured: femoral nerve, sciatic nerve, and superior gluteal nerves. []
Conclusion
The most encountered complications after hips arthroplasty are: death, dislocation and infection.
Monopolar Austin Moore and bipolar hemiarthroplasty has a beneficial effect has a beneficial
effect on the patient by reintegration into everyday life, the ability to move and also increases life
expectancy.
Keywords: hip arthroplasty, dementia, complications
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Introduction
Age is one of the most important parameters influencing the occurrence of hip fractures in
patients over the age of 65 but also their mental state is a decisive factor. In orthopaedic
departments in hospitals, orthopaedic trauma is very common and hip fractures are found in 20%
of cases, 50% are intracapsular fractures of the femoral neck. Elderly have eight times higher risk
of dying of a hip fracture if we compared to those people without a hip fracture. The risk of die it’s
very high in the first three months but still continuing in first ten years. High incidence of hips
fracture and dementia in the world wide include: Europe and Middle East part of Europe, South
America, Canada, United States and Asia. There is a very high probability that patients with hip
fractures and dementia to develop delirium that will result a longer hospitalizations and poor
mobility. [1-4] Death is not a common complication of hip arthroplasty, under 1% patients in
United States died, but in the first 90 days postoperative mortality it is a little bit higher than 1%.
In otherwise after revision surgery the percent is higher.
A study shows that the most common postoperative complications are: dislocation, infection
(the most common are Gram-positive Staphylococcus aureus – MRSA and Gram-negative
bacillus), nerve injury, cognitive and neurological alterations approximately 20% of patients are
affected, cardiopulmonary diseases, venous thrombosis, gastrointestinal bleeding, urinary tract
complications, intraoperative anaemia, hydro electrolytic disorders and pressure scars.
In patients over 65, cognitive impairment occurs in 10% of cases and most of them have
difficulty concentrating, writing, reading, but essential daily activities can do. The problem of these
disorders is unknown, but it is assumed that the neurotoxic effect of anaesthesia may be a
contributory factor. The appearance of delirium is a normal symptom in nearly a third of patients,
becoming hyperactive or hypoactive (age-related, alcohol-consuming, pre-operative drugs such as
benzodiazepine). It has been reported that spinal anaesthesia probably reduces the risk of delirium
after surgical surgery, as well as the administration of oxygen to a saturation greater than 95%. It
has also been found that analgesics reduce the risk of delirium while antipsychotics, sedatives do
not give the desired response.
In terms of lung problems in patients over 70 years of age with hip fractures, there is an
exacerbation of chronic lung, atelectasis, difficulty breathing, pneumonia, pulmonary
thromboembolism.
The most common gastrointestinal problems are: dyspepsia, abdominal distension and
constipation. Postoperatively, stress ulcer may also appear as a complication of surgeon surgery
that can be prevented with antacids and proton pump inhibitors. A common problem with surgical
patients is the inability to eliminate urine that can complicate infection and serious kidney
problems. The urine sample should be suppressed the next day postoperatively. The most common
infections of the urinary tract are the nosocomial cause. These may cause the delirium and may
prolong the duration of admission and may contribute to death [5-8].
The American Heart Association suggests that there are less than 5% of patients with hip
fractures who experience postoperative cardiac complications, but the mortality rate rises in the
first year to 20%. The most common causes of mortality are: myocardial infarction and deep vein
thrombosis. Prophylaxis of low-molecular-weight heparin deep vein thrombosis reduces its
appearance by 60% because it causes vasodilation and maintains blood flow to the extremities, also
inhibiting platelet formation and adherence to the endothelium.
Intraoperative is the occurrence of anaemia at 24-44%. Explanatory work because preoperatory
can lose about 500 ml of blood and can form a hematoma that can be evacuated during surgery.
Anaemia can also be affected by age, heart and lung problems, fracture type and anaesthesia.
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Haemoglobin values below 10 <g/dL are an important factor in mortality.

From an endocrine point of view malnutrition occurs between 20-70% in patients with hip
fractures, hospitalized. It affects many organs and systems, which is what causes sarcopenia and
mental, cardiac and immune problems. Also, in these patients, pressure scars and the occurrence
of infections are much more common. Decompensated type II diabetes is associated with an
increase in the number of perioperative infections and the occurrence of coronary problems.
Pressure scars occur due to the accumulation of force of extrinsic and intrinsic factors, and the
most common areas are in the lumbosacrata region. In 35% of cases there is a decubitus ulcer in
the first week of hospitalization. Also influenced by: age, malnutrition, nutrition, bed type [9-14].
Depending on the type of surgeon’s preferred type of surgeon, the following nerves may be
injured: femoral nerve, sciatic nerve, and superior gluteal nerves.
To prevent loosening of the aseptic implant, the shape and materials of the prostheses have long
been studied. The porous surfaces, the use of cement and the organic coating of the prosthesis
components make a perfect integration of the implant. Hydroxyapatite has the role of permanently
fixing the implant in the bone and determines the creation of a biological link between the implant
and the bone. The combination of the porous surface of the cup with the hydroxyapatite
conductivity determines bone growth between the acetabular cavity and cup also ingrowth between
femoral component and femoral bone.
Methods and Results
A one-year retrospective study with 150 elderly patients, women and men with the same
pathology as femoral neck fracture. All patients presented to the emergency room with hip
fractures, osteoporosis and dementia. In the first 24 hours of hospital is being administered
prophylaxis of venous thromboembolism with low molecular weight heparin and continues for 35
days postoperatively. Patients return to control at 2.4 weeks and 2.6.12 months respectively.
From 150 patients, 82 are males and 68 are females and the mean age is 71.4 years. In terms of
Garden classification, 139 patients have Garden IV fractures and 11 patients have Garden III
fractures. It is found that women have more frequent comorbidities. It is also found that
intraoperatively the most common complication is the loss of excessive amounts of blood and a
large number of patients need blood transfusions. Intraoperative mortality is not met. The rate of
mortality in the first year of this pacient is under 10%.
The most common complications with a rate of occurrence in 23% of cases are: infections,
dislocations, pulmonary embolism, vicious ossification and death. Compared with the literature,
where a mortality rate of 25% is specified in the first year, in this study mortality rate was 11%.
Other study was conducted on 184 patients, of which 46 men and 136 women who used this
type of prosthesis were then clinically and radiologically assessed at 1.3.6, 1 year and after. From
a clinical point of view, the Harris hip score has been made: the level (pain, function, appearance
of the deformities), daily activities (climbing stairs, ability to clothe and stretch, distance travelled)
while the WOMAC test is used also for measuring the pain level, the ability to perform regular
movements, but also to evaluate mental functions. In 85% of patients studied with the Harris Hip
Score grid, the feedback is good or very good.
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Conclusion
The most encountered complications after hips arthroplasty are: death, dislocation and infection.
Monopolar Austin Moore and bipolar hemiarthroplasty has a beneficial effect has a beneficial
effect on the patient by reintegration into everyday life, the ability to move and also increases life
expectancy. [13-15]
REFERENCES
1. Beaupre LA, Cinats JG, Senthilselvan A, Redued morbidity for elderly patients with a hip fracture after
implementation of perioperative evidence-based clinical pathway.
2. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women
3. Lyons A. Clinical outcomes and treatment of hip fractures.
4. Marcia G. Ory, PhD, MPH,1 Richard R. Hoffman III, MA,2 Jennifer L. Yee, PhD,3 Sharon Tennstedt, PhD,4
and Richard Schulz, PhD5.
5. Dearborn JT, Harris WH. Postoperative mortality after total hip arthroplasty. An analysis of deaths after two
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prognosis. J Bone Joint Surg Am. 1991; 73: pp. 1074-1080.
13. Edwards BN, Tullos HS, Noble PC. Contributory factors and ethiology of sciatic nerve palsy in total hip
arthroplasty. Clin Orthop. Relat. Res. 1987; 218: pp. 136-141.
14. Cohen B, Bhamra M, Ferris BD. Delayed sciatic nerve palsy following total hip arthroplasty. Br J Clin Pract.
1991; 45: pp. 292-293.
16. Hurd JL, Potter HG, Dua V, Ranawat CS. Sciatic nerve palsy after primary total hip arthroplasty: a new
perspective. J Arthroplasty. 2006; 21: pp. 796-802.
17. Hannouche D, Nich C, Bizot P, Meunier A, Nizard R, Sedel L. Fractures of ceramic bearings: history and
present status. Clin Orthop. Relat Res. 2003; 417: pp. 19-26.
18. Park YS, Hwang SK, Choy WS, Kim YS, Moon YW, Lim SJ. Ceramic failure after total hip arthroplasty with
an alumina-on-alumina bearing. J Bone Joint Surg Am. 2006; 88: pp. 780-787.
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Work-related Temporomandibular Joint Disorders and Cognitive

Behavioural Therapy in Dental Medicine Practitioners
CHECHERIȚĂ Laura Elisabeta1, CĂRĂUȘU Elena Mihaela2,

BURLEA Lucian Ștefan3, LUPU Costin Iulian3, STAMATIN Ovidiu4,
CIUBARA Anamaria5
1 Grigore T. Popa University of Medicine and Pharmacy, Faculty of Dental Medicine, Discipline of Odontology, Periodontology
and Fixed Prosthesis, Iasi, (ROMANIA)
2 Grigore T. Popa University of Medicine and Pharmacy, Faculty of Dental Medicine, Discipline of Public Health and
Management, Iasi, (ROMANIA)

3 Grigore T. Popa University of Medicine and Pharmacy, Faculty of Dental Medicine, Discipline of Public Health and
Management, Iasi, (ROMANIA)

4 Grigore T. Popa University of Medicine and Pharmacy, Faculty of Dental Medicine, Discipline of Oral Implantology, Iasi,
(ROMANIA)
5 “Dunarea de Jos” University, Faculty of Medicine and Pharmacy, Discipline of Psychiatry, Galați, (ROMANIA)
Email: mihaelacarausu@yahoo.com
Abstract
The temporomandibular joint (TMJ) imbalances and dysfunctions can lead to a group of
different affections named temporomandibular disorders (TMDs). Dental Medicine practitioners
with work-related TMDs are experiencing severe phenomena due to instability centric relationship,
craniomandibular mal-relations, hypotonia and general chronic diseases. The aim of our study is
to investigate the efficiency of the multimodal treatment followed by prosthetic-aesthetic and
gnathological treatment. This prospective study is based on data obtained from 62 patients, aged
25-64. The data were analysed by correlating the independent variables with the dependent ones
and the prevalence of TMDs. Study results revealed a high prevalence of work-related TMDs
(27.35%) in Dental Medicine practitioners. The prevalence of TMJ pain (54.24%) was high also.
After the pharmacologic medication, cognitive-behavioural therapy in association with
prosthetic-aesthetic and gnathological treatment, the prevalence of pain decreased (at 45.76%).
In conclusion, the multimodal therapy (pharmacologic medication, cognitive behavioural
therapy followed by prosthetic-aesthetic and gnathological treatment) determine the improved
outcomes in dental medicine practitioners with work-related TMDs not only in terms of pain and
neuropsychic manifestations, but also clinically, meaning at the TMJ function level and in all the
facial and oral aspects.
Keywords: dental public health; work-related TMDs; dental medicine practitioners (DMP); dysfunctional syndrome of
stomatognathic system (SDSS); cognitive behavioural therapy (CBT); prosthetic-aesthetic and gnathological treatment
1. Introduction
The dental medicine practitioners (prosthodontists, endodontist and other staff working in the
dental offices/clinics, even dental medicine students and residents), should be aware of the specific
risk factors and take measures to prevent or avoid the work-hazards [1, 2].
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Practicing dentistry cannot be considered as an easy job as it involves repetitive, awkward or

stressful motions of hands and wrists and even working in same posture for a long time [3]. These
can result in discomfort, pain and illness leading to musculoskeletal disorders and can result in
disruption or impairment of dental practice [4].
Musculoskeletal Disorders (MSDs) are injuries and disorders that affect the human body’s
movement or musculoskeletal system (i.e., muscles, tendons, ligaments, nerves, discs etc.) [5].
When a dentist is exposed to work-related MSDs risk factors, they begin to fatigue. When
fatigue outruns their body’s recovery system, they develop a musculoskeletal imbalance. Over
time, as fatigue continues to outrun recovery and the musculoskeletal imbalance persists a work-
related MSDs develops [6]. So, work-related musculoskeletal disorders (WMSDs) is the name the
U.S. Occupational Safety and Health Administration uses to describe a type of injury that results
from chronic overuse or misuse of soft tissues during work [7].
An inappropriate setup of working area, make the dental practitioner to assume many harmful
working postures while performing various treatment procedures on the patient [8, 9]. These
positions result in pressure on nerves and blood vessels, resulting in excessive strain on muscles,
thus decreases circulation and results in wear and tear on the joint structures [10].
2. Aim and Objective
Dental medicine professionals often have to limit or even abandon their professional activities
as a result of work-related TMDs. In view of this, our present study objective was undertaken to
evaluate the prevalence of TMDs among dental medicine practitioners (DMP) due of their work
activities and in special of the dysfunctional syndrome of stomatognathic system (SDSS) among
them and its multimodal therapy.
3. Material and Method
Our descriptive study took place in Iasi and Galati, between September 2017 to September 2018,
on a group of 63 dentists aged between 25 to 64, from North-East of Moldavia who work more
than 8 hours/day, the mean age of total studied group being 44.2 (+/- 12.6) years. The response rate
was 95.16% (59 dentists). So, from final studied group, 28 (47.46%) were subjects on feminine
gender and 31 on masculine gender (52.54%).
Our paper has two principal kind of proposal approach: first is the application of a questionnaire
for demographic data and identification of work-related TMDs in DMP; second is the effectiveness
of TMDs therapy.
Data concerning general, oral and mental health were retrieved from DMP with painful TMDs
according to the research diagnostic criteria.
The inclusion criteria in our study were: the agreement to participate in the study; age 25-60;
patients with definite diagnosis of TMDs. Also, in the last 90 days, all patients had to have
experienced: pain complaints in the temporomandibular region (or chronic pain at the level of
stomatognathic system and cephalic extremity); the presence of muscular tonus and muscular
contraction alterations or muscular dysfunction (such, limitation of mouth opening, and deviation
of mandible from the medial line during the opening, fatigue of cephalic extremity muscles and
functional alteration of stomatognathic system).
From the study were excluded: DMP who refused to participate; the uncooperative subjects or
those who did not respect the treatment. Also, were excluded the DMP with TMJ affliction, trauma,
rheumatoid arthritis or neoplasm and with all the other conditions that mimic the TMDs.
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Study protocol
We start the study (step 1) with the questionnaires: a) “TMJ pain screener” for TMJ pain, in the
mandible or in the muscles, in the last 90 days [11]; b) “Symptoms of TMDs questionnaire” for
subjective symptoms [12].
The pain is the most common TMDs symptom. The pain is disabling and can impair cognitive
functions, disrupt the sleep cycle, lead to a decrease in activities of daily living and stop persons to
participate to social activities and work. Nowadays, it is recognized that chronic pain is influenced
by a dynamic interaction between physical, psychological and social factors [13].
The step 2 of our study was the TMJ objective examination for clinical signs and a muscular
examination [14]; TMDs diagnosis was based on a standard clinical examination and paraclinical
exams (as TMJ tomography).
The TMDs multimodal therapy included: a) administering the anti-inflammatory medication to
control pain and the SDSS major symptoms; b) the cognitive behavioural therapy (CBT) for dental
medicine practitioners with TMDs; c) prosthetic-aesthetic and gnathological treatment.
Prior to prescribing the drugs, we considered the following: the existence in patients’ history of
any allergic reactions or adverse reactions; the evolution of the symptoms under treatment were
monitored [15].
Variables
In our study, the demographic factors considered as independent variables were: age, gender
(male/female). As dependent variables have been taken: the general health indicators (as pain), the
symptoms of TMDs, the results of objective TMJ examination for clinical signs or muscular
examination and the use of dental prosthesis, the results of cognitive behavioural therapy for
TMDs.
The statistical analysis was performed with the SPSS 20.0 software package for Windows [16].
The obtained data allowed for the classification of patients with respect to gender distribution,
age groups distribution, clinical aspects, TMDs treatment instituted, appreciation of chronic pain
and mental health indicators.
Patients were informed about the study and the content of the questionnaires and appropriate
consent were taken from all the subjects.
4. Results
General characteristics of the studied group

In the final studied group were included 59 patients: 28 (47.46%) feminine gender and 31
(52.54%) masculine gender (Fig. 1), the gender ratio being F/M=31/28= 1.10/1; 17 patients work
in dental offices from rural area (28.81%) and 42 patients work in dental offices from the urban
area (71.19%). Also, the patients were classified on age groups: 27 (45.76%) were aged 25-44 and
32 (54.24%) aged 45-64 (Table 1).
At start of our study, the calculated prevalence of TMDs in dental medicine practitioners was
57.62% (34): in male 58.06% (18 patients) and 57.14% (16 patients) in female gender subjects.
The self-reported pain disclosed the chronic TMDs in studied dentists. However, pain is the
primary problem of this pathology and it is typically the reason for patients to request medical care.
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Feminine gender
Masculine gender
47.46% 52.54%
Fig. 1. Gender structure of studied group
Table 1. General characteristics of the studied group

Age: 25-60 years Pearson’s χ2
Gender: Male Female Total Degrees of freedom p value Statistical
n1 (%) n2 (%) N (%) χ2c (DF) Significance
Variables: 31 52.54 28 47.46 59 100.00
Social environment:
-urban; 20 47.62 22 52.38 42 71.19 1.417 1 0.233897 NS
-rural. 11 64.71 6 35.28 17 28.81
Age groups:
-25-44 years; 14 51.85 13 48.15 27 45.76 0.01 1 0.920344 NS
-45-64 years. 17 53.12 15 46.88 32 54.24
The prevalence of TMDs symptoms before treatment is presented in table 2
Table 2. Results of the self-administered questionnaire for reported TMDs symptoms

Item: Both: Left: Right: Prevalence (%)
No. (%) No. (%) No. (%) before treatment after treatment
1. Do symptoms affect one or both TMJ? 8 (23.53%) 14 (41.18%) 12 (35.29%) TMDs: 34 (57.62%)
2. Pain in TMJ 6 (17.63%) 13 (38.24%) 13 (38.24%) 32 (54.24%) 27 (45.76%)
3. Grating sound in TMJ 5 (14.71%) 14 (41.18%) 11 (32.35%) 30 (50.85%)
4. Pain in lower jaw 9 (26.47%) 7 (20.59%) 16 (47.06%) 11 (32.35)
5. Pain in upper jaw 8 (23.53%) 10 (29.41%) 18 (52.94%) 13 (38.24%)
6. Pain in ear 5 (14.71%) 9 (26.47%) 11 (32.35%) 25 (74.53%)
7. Pain in facial areea 4 (11.76%) 2 (5.88%) 6 (17.65%)
8. General Pain constant: intermittent: 37 (62.71%) 27 (45.76%)
22 (37.29%) 15 (25.42%)
8. Headache and/or hemicranian pain 23(38.98%) 13 (22.03 %) 11 (18.64%) 47 (76.66%) 28 (47.48%)
10. Partial inability to open the mouth constant: sporadic: 17 (50.00%) 12 (35.29%)
1 (1.69%) 16 (47.06%)
11. Do you have arthritis? 16 (27.12%)
12. Have you had your teeth straightened (orthodontia)? 22 (37.29%)
13. Have you had any treatment for the work-related health problems? 34 (57.62%)
14. Have you had any anti-inflammatory drugs for relieve the pain? 36 (61.07%)
15. Have you had your bite adjusted by your dentist? 19 (55.88%)
TMDs severity
Before treatment, the severity of TMDs was: 38.33% (in 13 cases) low, 47.06% (in 16 cases)
medium and 14.71% (in 5 cases) severe. After treatment, the severity of TMDs decreased (with
26.47%), both in male (with 27.77%) and female gender (with 25.00%) patients.
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Also, after treatment it can be noted a decrease of constant moderate pain prevalence (with
17.66%) and a growth of pain free prevalence (from 5.88% to 20.59.
After treatment, the prevalence of pain detected at palpation by examiner decreased (with
29.71%) in the studied group, both in male (with 33.33%) and in female gender (with 25.00%)
patients.
The prevalence of headache attributed to TMDs decreased (with 11.76%) in total group. After
treatment, in male gender subjects it can be noted a decrease of headache prevalence attributed to
TMDs (with 11.11%). Similarly, in female gender subjects were observed a decrease (with
12.05%) of the headache prevalence; that is attributable to the multimodal treatment of TMDs.
Neuropsychic affectation
Patients with chronic TMDs may suffer also psychological. Treatments and recurrent pain
contribute to distress (20.59%) also (Fig. 2).
80
57.62%
60 47.48%
20.59%
40
14.76%
20
0
Headache Distress
Before treatment After treatment
Fig. 2. Prevalence of neuropsychic affectation in TMDs patients
At the beginning of our study, the prevalence of depressive manifestations was high (20.59%)
in TMDs patients; after multimodal treatment (pharmacological followed by prosthetic-aesthetical
treatment and cognitive-behavioural therapy), the prevalence decreased at 14.76%.
Multimodal treatment effectiveness

The effects of the anti-inflammatory drugs were preserved throughout the time of treatment; it
can also be mentioned that the improved outcomes were not only in terms of pain but also in terms
of clinical function of the TMJ.
The results of the study obtained from the batch of patients after the evaluation of applying
cognitive- behavioural therapy procedures were as follows:
No. of patients Score (scale of 0-10)

3 (8.82%) 8
5 (14.71%) 7
11 (32.35%) 6
12 (37.50%) 5
2 (5.88%) 4
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The prosthetic-aesthetical treatment has been applied simultaneously. The 5 patients (14.71%)
reject the prosthetic treatment and in 2 (5.88%) cases was used the method of relaxation mouth
guards.
4. Discussions
Work-related musculoskeletal disorders are on the rise worldwide. In the dentistry professions
these disorders have numerous repercussions, from serious ill-health effects at the individual level
to decreased workplace efficiency and productivity affecting not only dentist’s quality of life but
also, the dentistry economic outcomes.
The unitary holistic vision supports the dishomeostatic theory in the generation of TMDs and
the idea of the conjugate action of trigger factors [17].
Because the ethiology of TMDs is still unclear, a wide range of therapeutic solutions has been
proposed in the last years in the literature, including occlusal appliances, prosthetic-aesthetical
treatment [18], physical therapies, drugs and cognitive-behavioural therapy modalities.
In dentists, the work-related TMDs contribute also to a high proportion of socio-economic costs,
which are usually associated with comorbidities, such as depression and other psychological
factors. Also, the loss of work and work productivity is a major issue to consider in dentists with
TMDs [19, 20, 21].
Patients with chronic TMDs usually present associated psychological factors that should be
managed with specific interventions. Cognitive behavioural therapy is one of the treatments
proposed to manage patients’ thoughts, behaviours and/or feelings that might exacerbate pain
symptoms. It is a non-invasive therapy and unlikely to have adverse effects [22, 23]. The literature
reports that cognitive behavioural therapy alone is not better than other interventions, but it is a
good complement, especially when adapting the treatment to the psychological characteristics of
the patient. Cognitive-behavioural therapy could have a beneficial effect in the treatment of TMDs
because of the reportedly high prevalence of psychological dysfunction in TMDs patients [24].
The psychic affectation is secondary to body shape changes (facial features, facet level, golden
proportions and intraoral signs) due to the projection of one’s own body morphology, which
determines the degree of comfort of the individual in the report with the normal body composition.
In conclusion, the multimodal treatment (pharmacologic medication, cognitive-behavioural
therapy followed by prosthetic-aesthetic and gnathological treatment) determine the improved
health outcomes in patients with the TMDs, not only in terms of TMJ pain and neuropsychic
manifestations (distress and depression), but also clinically, meaning at the TMJ function level and
in all the facial and oral aspects.
Contribution of the authors: all authors have equally contribution.

Conflict of interests: nothing to declare.
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Pain Management among Dentists: An Alternative Approach. Holist Nurs Pract; 29: pp. 385-90.
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orthodontists: Risk assessment and prevention. Work; 52(3): pp. 559-79.
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a brief and effective temporomandibular disorder pain screening questionnaire: reliability and validity. JADA,
142: pp. 1183-91.
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The Value of Cognitive Therapy in the Treatment of Dental Phobia
STAN Dorina1, VOICU D.F.1

1 Faculty of Medicine and Pharmacy, “Dunarea de Jos” University Galati (ROMANIA)
Abstract
Dental phobia is one of the main barriers that hinder patients from using dental services, with
repercussions not only at the level of the oral cavity, but over the entire body. The problem requires
a multidisciplinary approach and a specific strategy. The purpose of the paper was to determine the
value of the cognitive therapy in reducing dental anxiety. 40 patients from a dental office (MDAS
≥13) were studied. Anxious reactions were evaluated with MDAS and DFS. Following the use of
cognitive technique, the level of anxiety decreased significantly for both the global anxiety index
and its components.
Keywords: dental phobia, cognitive therapy
Introduction
Fear is a normal emotional reaction to one or more specific threatening stimuli [1]. Dental
anxiety indicates a state of apprehension, that something awful will happen, in connection with
dental treatment and it is usually accompanied by a feeling of loss of control. Thus, dental phobia
is a severe type of dental anxiety, characterized by marked and persistent anxiety, in relation to
clearly visible situations or objects (e.g., drilling, local anaesthetic injections) or the environment
of the dental office, in general. The term combined – “dental phobia and anxiety” (DFA) – is often
used, to define the strong negative feelings associated with dental treatment among children,
adolescents or adults. Dental phobia can include fear of dental procedures, the environment or
dental settings, fear of dental instruments or even the fear of the dentist, as a person [2].
Stubbornly avoiding contact with the dentist and his office can have devastating consequences,
not only at the denture level, but also on the entire body. Thus, the fight against dentophobia
becomes a public health problem. Although important progress has been made in this regard, in the
last 50 years, dental phobia remains a chapter open to interdisciplinary discussions and research
[4].
Combating dental phobia requires a specific strategy for addressing patients [3]. After
identifying the dental anxious patients (during an initial conversation, in a neutral room, without
stimuli, such as sounds, smells and dental equipment), the level of dental anxiety (interview,
MDAS and DFS questionnaires) is evaluated and the therapeutic strategy established. Dental
anxiety can be part of a complex disorder, requiring specialist attention and good cooperation
between dentist and psychologist [5].
One of the methods to reduce the level of anxiety is cognitive therapy, which aims to restructure
the content of negative thoughts and increase the patient’s control over their own cognitions and
emotions [6]. It is very important and strongly recommended, that the patient be told what to
expect, what measures are being taken, to make the dental treatment as comfortable as possible,
and also to ensure safety and control regarding oral care [7]. This type of information and specific
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explanations provide patients with a realistic perspective, on the feared situation, with the
improvement of their comfort and safety in dental care.
The present study covers 100 patients of a private dental office, of which 40 (22 men and 18
women), meet the criteria for inclusion in the research project (the assessment of the anxiety level
calculated scores above the MDAS≥13 average). Their age ranged from 19 to 65 years (average
age 33,5 years). By completing the questionnaires, the subjects gave themselves practically, the
agreement to participate in the study, having guaranteed the confidentiality of the result.
The study aims to demonstrate the application of cognitive restructuring, to a sample of phobic
dental patients, causes a significant decrease in general anxiety level; the effect of a method for
reducing dental phobia is the reduction of the avoidance-anticipation anxieties, of the physiological
anxiety during treatment and of the level of anxiety for stimuli and situations for their dental
treatment.
The methods applied were:
– theoretical – evaluation of the level of dental anxiety with two specific questionnaires for
dentistry: MDAS (modified scale of dental anxiety) and DFS (Dental Fear Survey). MDAS can be
used to screen all new patients older than 12 and it can calculate anxiety. It contains 5 questions,
which the patient has to rate with 1-5. The MDAS score ranges from 5 (without fear) to 25 (extreme
fear); score >19 indicates a medium or high level of anxiety. MDAS evaluates five anxiety-
generating moments: the day before the treatment, in the waiting room, on the dentist’s chair,
anticipating dental depuration, on the dentist’s chair, anticipating dental filling and on the dentist’s
chair, anticipating local anaesthetic injection [8].
DFS applies to patients already diagnosed (with MDAS) as being anxious. This test
demonstrates a patient’s avoidance behaviour, which refers to physiological and specific triggers,
to fear, during dental treatment. Containing twenty questions, rated with 1-5, the score ranges from
20-100, with a score >60 indicating a high level of anxiety [9]. The global index results from adding
the values of the 20 articles or the 3 subscriptions. Values of 48-75 show medium scores, while
values >76 show high scores.
– investigation – intervention experiment: cognitive restructuring, as a method of reducing
anxiety at treatment; – statistic methods – descriptive analysis.
The factual material was randomly divided into a study group (20 patients) and a control group
(20 patients). Four sessions of cognitive restructuring techniques were applied to reduce anxiety.
The therapy progressed as follows: based on the information obtained at admission, the initial
discussion with the patient carefully evaluated his thoughts, beliefs, attitudes and opinions
regarding dentistry and his own dental care behaviour. The patient was convinced that the defective
cognitions come from the previous ones, the learning and the possible sources of this knowledge
were identified and discussed. The treatment was described to the patient as an exploration of the
sources of cognitive restructuring of fear (modification of negative cognitions), the provision of
information (about oral health and dental treatment) and as a way to better manage the dreaded
situations. No relaxation training was used.
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The research was of a pretest-retest type, with the levels of anxiety recorded before and after the
interventions, using the DFS questionnaire, with both global components and sub-components:
physiological, anticipation-avoidance and anxiogenic stimuli.
For the intervention group, the overall score of DFS before therapy is 78.25 (DS±4,002) and
after the intervention is 62.11 (DS±3.992). For the control group, the overall score of DFS before
therapy is 68.60 (DS±8.325), and after the intervention is 68.40 (DS±8.325) (Table 1).
For the intervention group, the differences on the avoidance-anticipation component show a
statistically significant difference (t=9.200, p=0.000<0.05), also for the physiological component
(t=14.371, p=0.000<0.05) and for the stimuli specific teeth (t=12,651, p=0.000<0.05).
The use of cognitive restructuring to reduce dental phobia leading to a decrease of anxiety level
on subcomponents, it is confirmed: the effect of the anxiety reduction method is manifested by the
decrease of the avoidance-anticipation anxiety, of the physiological anxiety, during the treatment,
and of the anxiety level at the stimuli, in specific situations for dental treatment.
Conclusions
The efficacy of cognitive restructuring techniques [10] for combating dental phobia, applied in
our case in four sessions, is confirmed by the substantial reduction of the level of anxiety,
statistically argued. Cognitive techniques for reducing dental anxiety had a statistically significant
effect, both for the general index (total DFS) and for the three components: avoidance,
physiologically and to stimuli, compared to the control group, where the differences of DFS are
negligible. As other similar studies [11], more complex and in larger groups of patients, our
notifications have shown that this method must be included in the therapeutic arsenal of dental
phobia.
Table 1
DFS score Cognitive tehnique Control group Group T independent test
N Median DS N Median DS t p
Global score
Before intervention 20 78,25 4,002 20 68,60 8,325 Interventional group 25,627 0,000
After intervention 20 62,11 3,992 20 68,40 8,325 Control group 1,710 0,107
Anticipation-avoidance
Before intervention 20 11,58 1,68 20 9.18 1,897 Interventional group 9,200 0.000
After intervention 20 9,21 1,36 20 9,13 1,868 Control group 1,000 0.330
Physiological anxiety
Before intervention 20 19,88 3,26 20 16.30 2,315 Interventional group 14,370 0,000
After intervention 20 13,72 2,80 20 16.30 2.323 Control group 0,000 0,000
Anxiety to stimuli
Before intervention 20 53,87 3,26 20 49,86 5,685 Interventional group 12,651 0,000
After intervention 20 39,45 3,34 20 44,70 5,737 Control group 1,831 0,083
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REFERENCES
12-20.
3. Bray, A., Chhun, A., Donkersgoed, R., Hoover, S., & Levitan, S., An evidence-based report investigating the
most effective method to reduce dental anxiety. Evidence Based Learning Module, pp. 12-16, 2009.
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modalities. Journal of Dental Education, 65(12), pp. 1357-1368, 2001.
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Masteroppgave, 9, 2012,
http://munin.uit.no/bitstream/handle/10037/4240/thesis
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in Reducing Dental Anxiety, Procedia – Social and Behavioural Sciences 149: pp. 302-306, 2014.
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Ketamine in Perioperative Depressive Symptoms (PDS)

Improvement – Review
MANOLE Corina1, SERBAN Cristina2, CIUBARA Alexandru Bogdan2,

CIUBARA Anamaria3
1 Ph.D. student, “Dunarea de Jos” University, Galati, (ROMANIA)
2 Clinique Surgical Department, “Dunarea de Jos” University, Galati, (ROMANIA)
3 Clinique Medical Department, “Dunarea de Jos” University, Galati, (ROMANIA)
Email: abciubara@yahoo.com
Abstract
Anxiety and depression are the most frequent psychiatric disorders associated to organic
diseases. PDS (Perioperative Depression Symptoms) represent a depressive episode which occurs
mostly in early postoperative phase. It was observed that the patients presenting PSD have a higher
risk of postoperative complications, an increased length of hospitalization and a more reserved
prognosis.
A series of recent studies have shown that the usage of ketamine in small doses reduces
significantly the major depression symptoms in short time after its administration. The ketamine
blocks the NMDA (N-methyl-D-aspartate) receptors, leading to the presynaptic release of
glutamate and increasing the activity of dopaminergic neurons with antidepressant role.
Keywords: ketamine, small doses, postoperative depressive symptoms, improvement
Ketamine – chemical denomination: 2-(2-chlorophenyl)-2-methylamino-cyclohexanone

(Figure 1). It is a derivate of fenilciclidine, antagonist of NMDA (N-methyl-D-aspartate) receptors
with minimum action on receptor’s GABA, on monoaminergic, muscarinic, nicotinic receptors and
on those for opioids [1]
Fig. 1 [2], [3]. chemical formula and atomic structure of ketamine
Ketamine depresses the neocortex and certain subcortical structures and stimulates the limbic
system and the hippocampus, performing a “dissociative” anaesthesia characterized by superficial
sleep, involuntary movements, spontaneous breathing, environmental detachment and strong
analgesia. It has a neuroprotective and immunomodulatory effect, reducing the effect of pro-
inflammatory cytokines (Figure 2) [5], being recently introduced in the treatment of depression.
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Fig. 2 [4]. Ketamine’s Action Mechanism
Recent studies have shown the rapid antidepressant effect of ketamine. The administration of
this anaesthetic substance in small doses has significantly reduced the symptoms of perioperative
depression. A marked reduction in anxiety, postoperative pain and delirium after surgery has also
been observed.
PDS (Perioperative Depressive Symptoms) is a type of depressive episode that occurs in patients
in the perioperative period, with predilection in the early postoperative phase. It is characterized
by extreme anxiety, irritability, fatigue, sleep disorders, guilt and suicidal ideation. Patients with
PDS have been observed to have a higher risk of postoperative complications, increased
hospitalization length and, in general, a more reserved prognosis [6, 7].
In order to assess the severity of depressive episodes in adults, the following scales are used:
MADRS (Montgomery-Asberg Depression Scale), HDRS (Hamilton Depression Rating Scale),
PHQ-9 (Patient Health Questionnaire), HADS (Hospital Anxiety and Depression Scale), etc.
HDRS is the most used scale for the selection and monitoring of patients in the research studies
on depression treatment [8, 9, 10]. The original version contains 17 items, with a system of
cumulated scores based on common symptoms of depression, respectively sleep disorders,
fluctuations of body weight, fatigue state, sexual dysfunctions and cognitive disorders [7].
Thakurta et al., have reported the significant improvement of depressive symptoms 80 minutes
after the drip with small doses of ketamine and observed that 77% of subjects have fulfilled the
answer criteria after one post-drip day. The response was maintained for one week for 13% of
patients.
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Yang Zhou et al., have studied the effect of low doses of ketamine in PDS (perioperative
depressive symptoms) in patients undergoing supratentorial brain tumour resections. Patients with
symptoms of moderate to severe depression were enrolled in the study, using the PHQ-9 and
MADRS scales. The target group of patients was given intravenous ketamine 0.5 mg/kg for 40
minutes after opening the dura mater. Small doses of ketamine were found to reduce the incidence
of PDS and postoperative pain during the recovery period [11, 12].
Zarate et al., report the amelioration of depressive symptoms 110 minutes after the
administration of ketamine in small doses (0.1-0.5 mg/kg). 71% of patients have fulfilled the
response criteria and 29% of remission, one day after administration in endovenous drip. The
response has been maintained for one week for 35% of the subjects [13].
Akira Kudoh et al., studied the effects of ketamine in depression patients undergoing
orthopaedic surgery. The study included patients with major depression, evaluated according to
Diagnosis and Statistical Manual of Mental Disorder, in at least one-year treatment with
antidepressants (imipramine, mianserin and clormipramine). The depression state was
quantitatively estimated 2 days before surgery and 1-3 days after surgery, using the HDRS scale.
The findings of this study showed that low doses of ketamine used intra-anaesthetically has
improved the postoperative depressive state and significantly improved patient’s pain after an
orthopaedic surgery [14].
SAD (Social Anxiety Disorder) is affecting around 12% of US adults, being defined as an
important and persistent fear against certain social situations, having a negative impact on the work
productivity, social relations and quality of life [15, 16].
Jerome H. Taylor et al., had studied the effects of ketamine on a lot of patients with social
phobia. The ketamine and placebo drips had been administered randomly, with a period of repose
of 28 days between the drips. The anxiety evaluations were made 3 hours after the drip and the
patients had been monitored for 14 days. The participants had significantly presented a response to
treatment after the drip with Ketamine (0.5 mg/kgc) as reported to placebo (normal saline solution).
This study proves the efficiency of small ketamine doses in the reduction of social anxiety [16].
In conclusion, we can assert that we can foresee the usage of ketamine in the improvement of
anxious-depressive disorders in the future. Anaesthetic induction with small ketamine doses has
improved the postoperative psychic status of patients with refractory depression at usual
treatments.
REFERENCES
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Social Media Addiction in Adolescents and Young Adults –

Psychoeducational Aspects
LUCA Liliana1, CIUBARA Alexandru Bogdan2, ANTOHE Magda Ecaterina3,

PETERSON Ioana4, CIUBARA Anamaria2
1 PhD student “Dunarea de Jos” University, Galati, (ROMANIA)
2 “Dunarea de Jos” University, Galati, (ROMANIA)
3 “Grigore T.Popa” University, Iasi, (ROMANIA)
4 Psychiatric Clinic Ryhov Region JonKoping, (SWEDEN)
Email: abciubara@yahoo.com
Abstract
In a contemporary society in which individuals declare themselves increasingly busy, it appears

that the prominent modality of relaxation and sometimes getting informed is the Internet. The
modern age is defined by consumerism, advanced technology, globalization and explosive
development of Mass Media. Adolescents and young adults have various information alternatives
at their disposal, but also a high level of expectations from their social and professional
environment. Therefore, feelings of doubt, anxiety and uncertainty may emerge, and different
inferiority complexes can develop, making one reach an impossibility of developing one’s identity,
in a form of compensatory mechanisms that appear at the attitudinal and behavioural level.
The present article aims to present the results of studies performed by our team on different
groups of subjects between the ages of 15 and 24, as a starting point for informing the population
about the medical risks they are exposed to, in order to prevent the effects of these behaviours that
affect the overall functioning of the individual.
Keywords: adolescents, young adults, social media, addiction, psychoeducation
Introduction
Excessive use of the internet on mobile phones is already considered a public health problem in
most developed countries. There are numerous worldwide studies in the field of new addictions
that highlight the unhealthy, psychopathological aspect of excessive use of social networks and
mobile phones [1, 2].
In our country, this issue is still insufficiently addressed by specialists.
However, neither in the specialized literature, nor in the prior conducted studies, there has been
a clear link been established between the worrying use of the Internet and an acceptable duration
that is not considered harmful to health. It is regarded as problematic with the occurrence of
behavioural changes, deterioration of family relationships and decrease of professional
performance [3, 4, 5].
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Methodology
The objective of this paper is the self-perception of addiction.

We did not set out to determine the predictors of these new addictions. Adolescents and young
people are considered high risk groups precisely because their personality structure is still in the
course of definitive formation. Anxiety, depressive states, feelings of loneliness can be both
predictors and effects of the overuse of the Internet. We analysed the vulnerabilities of the subjects,
identified personality traits and gender and age differences [6, 7].
The questions focused on aspects of personal identity – the description of free time activities,
specific social elements, the relational network including family, friends, partners.
We wanted to determine if there are mobile phone applications with functions that can become
indispensable to the people studied.
We are also interested in what motivates them to use the Internet, what is their favourite social
network, their favourite device and how many hours they spend daily in the virtual environment.
Results
A first study conducted had as a working method a questionnaire on the phenomenon “Selfie”.
We investigated 180 subjects aged between 18 and 25 years, 49.4% between 15 and 19 years,
50.6% in the age group 20-24, 75% female and 25% male.
The results of this study showed that 99.4% of them are familiar the term “selfie”, 71.1% are in
the habit of taking their own photos, 4.7% of them take a selfie weekly. 14.4% of them post a selfie
daily.
Among the reasons described by the subjects for taking selfies, we mention the following: 85%
take selfies for the purpose of posting them on social networks, and 37.5% do this for no particular
reason.
When asked the question “What is the reason for posting?” This way, 61.7% mentioned their
desire to share their status with their friends and 26.1% wanted to show their location to their
friends.
For 69.4% of them, the most frequently used social network where they post selfies is Instagram.
Other results show that 81.7% of subjects post when they think they look attractive.
In the case of the 77.8% of subjects verify who likes or reacts to the photo, 8.9% of them check
every 5 minutes, 29.4% check every hour.
In another study we conducted, we used a survey that included questions about the Facebook
network. We investigated a number of 115 subjects, 33% between the ages of 15-19 and 67%
between 20-24, 81.7% of the subjects were of female gender and 18.3% were of male gender.
Results showed that all the investigated subjects have a user account on Facebook and 99.1%
of them have had an account for more than one year.
All the participants in this study have personal information displayed on their profile and have
a real profile photo, and 78.5% of them mention the place where they live on their profile.
Although 67.5% of the subjects do not know personally all the people in their friend list, we
found out that 9.6% use the network daily to socialize with friends they don’t know or haven’t met
in real life.
Out of the subjects, only 8.7% check on their friends’ accounts daily.
Also, 78.3% of them believe that Facebook facilitates their access to information that otherwise
would have been unavailable to them.
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The reason that led them to create an account on Facebook was to constantly stay in contact
with friends, as 98.3% of them use Facebook for its chat feature.
All subjects surveyed check the account daily, 15.7% of them spend more than 3 hours on this
network, 68.7% perceive that Facebook is addictive and 97% of them declare they would be
affected by the absence of this network if it were to disappear.
Among the ways they spend their free time, 66.1% of the subjects answered that they are
watching movies, 54.8% said they go out with friends, 40% said they go out with friends on a
weekly basis and 52.2% use social networks during their leisure time.
Another study we will be referring to examines young people’s perception of psychiatry and
psychotherapy. Of a group consisting of 150 subjects, 40% said they had never resorted to
psychotherapy, 75% knew people who went to a psychologist, 35% said they would be reluctant
to address to mental health specialists if they had an emotional problem, 30% of them would not
like to be known that they had been in psychotherapy, 90% believe that mental health services are
beneficial and 77.1% said that if they would be diagnosed with a mental illness, they would not
accept psychotropic medication.
Preliminary results of an underway study regarding the use of mobile phones, on a lot of 125
subjects aged between 15 and 24 years, have shown that all those surveyed use the mobile phone
more than 5 hours a day, they prefer written messages instead of the classic phone call, they prefer
to use mobile data instead of minutes on the network, and the main reason they spend time on the
phone comes from the desire to be permanently up to date with what activities those in their friends
lists do.
Another relevant aspect is that on the question “Do you have health problems?” many of them
answered that in recent months they were experiencing joint pain in the hand they are using the
phone with.
Collaboration with an orthopaedic physician confirmed that overuse of the mobile phone could
trigger Carpal Tunnel Syndrome, something already mentioned in the literature. The aptitude
deficit is part of the global functioning and overall well-being of the individual.
The strength of this study resides in the complexity of the answers given.
The corroborated results of the studies discussed show that the participants have a need to belong
to a group, a need to control their context and the people from their social environment as well as
their virtual space, along with a need to feel constantly present in their social life.
Recent studies show that adolescents give away their personal data with great ease when
interviewed by strangers, a fact confirmed in our research by the large percentage of subjects who
communicate with people they do not know in real life, but to whom they make confessions, as
they do not consider the virtual space to represent a danger to them.
The results of the surveys show that the subjects do not consider themselves addicted, although
over 70% of them spend at least 4-5 hours daily using different applications installed on the mobile
phone.
Conclusions
In conclusion, there is an imposing need for informing on the risks posed by adolescents and
young adults, in order to prevent the development of psychopathological symptoms, as well as
problems of somatic nature. The role of the family in shaping the personal and social identity of an
individual is essential.
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REFERENCES
1. Bardi, C.A., Brady, M.F. (2010) Why shy people use instant messaging: Loneliness and other motives.
Computers in Human Behavior 26 (6), pp. 1722-1726.
2. Bernicot, J., Volckaert-Legrier, O., Goumi, A., Bert-Erboul, A. (2012) Forms and functions of SMS
messages: A study of variations in a corpus written by adolescents. Journal of Pragmatics 44 (12), pp. 1701-
1715.
3. Skierkowski, D., Wood, R.M. (2012) To text or not to text? The importance of text messaging among college-
aged youth. Computers in Human Behaviour 28 (2), pp. 744-756.
4. Thomée, S., Eklöf, M., Gustafsson, E., Nilsson, R., Hagberg, M. (2007) Prevalence of perceived stress,
symptoms of depression and sleep disturbances in relation to information and communication technology
(ICT) use among young adults – an explorative prospective study. Computers in Human Behaviour 23 (3),
pp. 1300-1321.
5. Walsh, S.P., White, K.M., Cox, S., Young, R.M. (2011) Keeping in constant touch: The predictors of young
Australians’ mobile phone involvement. Computers in Human Behaviour 27(1), pp. 333-342.
6. Pascu S. L., Domenico P., Bradeanu v. A., Ciubara, A., Marin M., & Marina V (2019). The Effects of Blue
Light in Modern Society. BRAIN. Broad Research in Artificial Intelligence and Neuroscience, 10(3), pp. 5-
11.
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The Link Between Lipidic Profile, Depression and Cardiovascular

Disease
ANGHEL Lucretia1,2, URSU Dumitru2, BAROIU Liliana1

1 Dunărea de Jos University of Galati, Medicine and Pharmacy Faculty, Department of Internal Medicine, 47 Domneasca Str.,
800008, Galati, (ROMANIA)
2 Emergency Hospital St. Apostol Andrei of Galati, (ROMANIA)
Emails: Lucretia.Anghel@ugal.ro, ursu.d@protonmail.com ,lilibaroiu@yahoo.com
Abstract
THE LINK BETWEEN LIPIDIC PROFILE, DEPRESSION AND CARDIOVASCULAR

DISEASE: The purpose of this study was to identify the connection between cardiovascular disease
and depression taking lipid profile as a common risk factor in the occurrence of both pathologies.

100 patients were examined for 3 months, admitted to the internal medicine department of St.
Andrew’s Emergency Hospital in Galati. Anamnesis was collected, electrocardiogram, objective
examination and lipid profile were performed. The Hamilton scale (HDRS-17) was used to assess
depression.
Results
In patients with depression, an increased prevalence of dyslipidaemia and obesity was detected,
especially in women. Of 10 women with mild and severe depression, all had altered lipid profile,
obesity or overweight and increased risk of cardiovascular disease.
Conclusions
Although it is claimed that depression would be an individual risk factor for the occurrence of
an adverse cardiac event, the comprehensive pathophysiological approach allows the identification
of risk factors for both CVD and depression as being largely common. Therefore, a coexistence
relationship is created. The other possible situations may arise due to the involvement of individual
protective factors and genetic vulnerability. As a result, treatment of depression may reduce risk of
cardiovascular event in some cases.
Keywords: Depression, cardiovascular disease, lipidic profile
Introduction
Depression is a mental condition marked by loss of interest and pleasure in ordinary activities,
profound sense of worthlessness and associated cognitive, physical, behavioural symptoms,
including anhedonia, sleep disorders and eating. It is a quite common nosologically entity (1 in 6
adults throughout life will suffer from depression, women being affected twice as much as men)
[1], and is ranked third according to the impact quantification [2]. Depression includes extensive
symptomatic variability in addition to the many subtypes, which can be differentiated by: duration,
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recurrence, occurrence under certain conditions, key symptoms [3], which makes it difficult to
diagnose in the presence of cardiac comorbidities. The intensity of the symptoms may be different
from one person to another, and may be given by the multitude of precipitating factors. Thus, cases
of mild to severe depression will be detected depending on the duration and intensity of the
symptoms. Therefore, the major target of the manifestations of depression is the quality of the
person’s life, which will be directly affected in proportion to the increase of the severity of this
pathology and may culminate even with the suicide. The establishment of the treatment will be
rational, in accordance with the severity of the symptoms, their duration, the subtype of depression,
the degree of functional impairment of the individual.
Mechanisms and Correlation
At the brain level through imaging investigations it was identified that there is a decrease in
blood flow, activity and connections between the prefrontal cortex and limbic and subcortical
structures, responsible for the speed of reaction and cognitive function, and hyperactivity of the
amygdala, which explains the lack control of emotions, mood, and increased anxiety [4-6]. The
mechanisms by which this occurs are not yet elucidated. For depression and CVD (cardiovascular
disease) the common link may be the existence of a chronic inflammatory process associated with
increased inflammatory markers such as: C-reactive protein, TNF-α and pro-inflammatory
cytokines [7].
However, it is relevant that depression does not appear to influence CVD by conventional risk
factors, and that lipid profile (high total cholesterol, and low HDL) is associated with a low level
of depression [8]. However, the treatment of depression with SSRI, reduces sympathetic activity
[9], and prevents serotonin binding by platelets that would initiate their aggregation in a specific
environment (atherosclerotic vessels), which contributes to diminishing the risk of a cardiac event.
Serotonin is also involved in the release of nitric oxide by the vascular endothelium, respectively
the presence of inflammation as well as atherosclerotic areas in the vessels, will decrease its release,
thus vasospasm will occur. Depression in patients without CVD was associated with endothelial
dysfunction, and treatment with SSRI produced significant improvements [10, 11]. Also, in the
etiopathogeny of depression, the behavioural component precipitated by psychosocial factors
(acute stressors: social conflict, social ties; chronic: work, family), which denotes that depressed
persons are less often engaged in activities that promote healthy lifestyle, they are not able to
maintain a diet, exercise regularly, and adhere to treatment [12, 13, 14].
The study group comprised a number of 100 patients from urban and rural areas who were
admitted to the Internal Medicine Department I within the Emergency Hospital “Apostol Andrei”
Galați. Patient evaluation was done by:
I Anamnesis:
1. Age, sex, marital status, occupation, level of training
2. hereditary-collateral history: death from cardiovascular disease under 55, familial
hypercholesterolemia, diabetes.
3. personal pathological history: the existence of chronic diseases, surgical interventions,
sexually transmitted diseases, relevant medication
4. Lifestyle: physical activity, nutrition, nicotine consumption, coffee
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II. Objective clinical examination: anthropometric data (height and body mass, waist, BMI
calculation (Body Mass Index)), pulse and blood pressure measurement (2 values every 3 minutes)
III. Investigations
• Electrocardiogram;
• Laboratory tests: serum creatinine, blood sugar, triglycerides, total cholesterol
The Hamilton Scale (HDRS-17) was used to determine depression in the patient group
The distribution of the group by sex was: 39 women and 61 men respectively. Of the 39 women
over the age of 65, 30 are smokers, 7 are with cardiovascular disease, 12 are at high risk, and 10
are at low risk of cardiovascular disease, respectively. Based on the fact that the BMI reference
values (Normal range 20-24.9; Overweight, 25-29.9 associate high risk, Obesity >30 – high risk)
and total cholesterol (120-200 mg/dl).
Of the 39 women, 17 have hypercholesterolemia, 10 are overweight, 13 have obesity, 7 have
mild depression, and 3 have severe depression.
Of 61 men (age range was 55-79 years), 18 have cardiovascular disease, 23 are at high risk, and
20 have no or low risk of cardiovascular disease. Of the 61 men, 28 are with cholesterol, 25 are
overweight, 2 men have mild depression and one with severe depression.
Of the 10 women with mild and severe depression, 6 are overweight 3 have obesity, most (10)
have high total cholesterol, 4 have high LDL-cholesterol, and all 4 have an increased risk of
cardiovascular disease. And the 3 men with mild and severe depression belong to the group with
high risk of developing CVD and have the other conditions.
Of the total group of patients (100), (87%) have a mean depression score of 8.2, which
corresponds to the norm, 4.4% have severe depression, and 9.9% have mild depression. The gender
distribution of the mean values of the other conditions shows that although women have higher
BMI, total cholesterol, and depression, men have a higher risk of developing CVD.
Conclusions
Although it is claimed that depression would be an individual risk factor for the occurrence of
an adverse cardiac event, the comprehensive pathophysiological approach allows the identification
of risk factors for both CVD and depression as being largely common. Therefore, a coexistence
relationship is created. The other possible situations may arise due to the involvement of individual
protective factors and genetic vulnerability.
Given that depression is found in large numbers among the population, its prompt and
appropriate treatment concomitantly with psychotherapy would allow both to improve the quality
of life of the people and to reduce the risk of CVD. In the case of CVD coexistence and depression,
the patient’s compliance with the treatment tends to decrease.
Modifiable risk factors such as: sedentary lifestyle, coffee, tobacco, unhealthy eating, excessive
alcohol consumption, should be given priority control in order to obtain positive results in
maintaining blood pressure and preventing depression.
The severity of depression correlates with the level of cardiovascular risk factors, so in major
depression types, blood pressure and cholesterol levels were higher on average. The establishment
of preventive health policies targeting the geriatric population, is an imperative in order to increase
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the quality of life, and implies the knowledge and identification of the geriatric particularities and
their approach at the individual level.
REFERENCES
1. Alonso J, et al., Prevalence of mental disorders in Europe: results from the European Study of the
Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. 2004. pp. 21-27.
2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med.
2006; 3: e442. doi: 10.1371/journal.pmed.0030442
3. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care
(IQWiG); 2006. Types of depression. 2012 Dec 5 [Updated 2017 Jan 12].
4. Murray DP, Metz NS, Haynes WG, Fiedorowicz JG. Vascular function is not impaired early in the course of
bipolar disorder. J Psychosom Res. 2012 Mar; 72(3): pp. 195-8.
5. García RG et al., Plasma nitrate levels and flow-mediated vasodilation in untreated major depression.
Psychosom Med. 2011 May; 73(4): pp. 344-9.
6. Savitz J, Drevets WC, Bipolar and major depressive disorder: neuroimaging the developmental-degenerative
divide. Neurosci Biobehav Rev. 2009 May; 33(5): pp. 699-771.
7. Dantzer R et al., From inflammation to sickness and depression: when the immune system subjugates the
brain. Nat Rev Neurosci. 2008 Jan; 9(1):46-56.
8. Shin JY, Suls J, Martin R, Are cholesterol and depression inversely related? A meta-analysis of the association
between two cardiac risk factors. Ann Behav. Med. 2008 Aug; 36(1): pp. 33-43.
9. Barton DA, Sympathetic activity in major depressive disorder: identifying those at increased cardiac risk? J
Hypertens. 2007 Oct; 25(10): pp. 2117-24.
10. Cooper DC et al., Adverse impact of mood on flow-mediated dilation. Psychosom Med. 2010 Feb; 72(2): pp.
122-7.
11. Pizzi C et al., Effects of selective serotonin reuptake inhibitor therapy on endothelial function and
inflammatory markers in patients with coronary heart disease. Clin Pharmacol Ther. 2009 Nov; 86(5): pp.
527-32.
12. Everson-Rose SA, Lewis TT. Psychosocial factors and cardiovascular diseases. Annu Rev Public Health.
2005; 26: pp. 469-500.
12-20.
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The Role of Polyunsaturated Fatty Acids in Neurocognitive

Development in Children
TRANDAFIR Laura Mihaela1, INDREI Lucian Laurențiu2*,

STÂRCEA Magdalena1, MIRON Ingrith1
1 University of Medicine and Pharmacy ‘’Grigore T. Popa’’ Iași, Pediatric Department (ROMANIA)
2 University of Medicine and Pharmacy ‘’Grigore T. Popa’’ Iasi, Preventive Medicine Department (ROMANIA)
* Corresponding author: INDREI Lucian Laurențiu
Emails: trandafirlaura@yahoo.com, lucian_indrei@yahoo.com, magdabirm@yahoo.com, ingrithmiron@hotmail.com
Abstract
Neurocognitive development in children is influenced by many factors, including nutrition.

Nowadays, there is an increasing interest in the effect of polyunsaturated fatty acids (PUFA –
polyunsaturated fatty acids) on cognitive brain development. Data from the literature show that a
balanced diet in PUFAs represented by omega-3 and omega-6 is extremely important to
neurocognitive and visual child’s development as well as in ensuring long-term health through anti-
inflammatory action. Omega-3 fatty acids (linolenic acid, eicosapentaenoic acid – EPA,
docosahexaenoic acid – DHA) play an important role in the optimal functioning of the nervous
system and visual function beginning with intrauterine life and continuing later in childhood and
adolescence. Since, according to literature, there are several considerations regarding
supplementation with PUFAs in children, it is essential to take into account both the benefits and
risks of administering them.
Keywords: polyunsaturated fatty acids, omega-3 fatty acids, omega-6 fatty acids, children
Introduction
Currently, the role of polyunsaturated fatty acids (PUFA – polyunsaturated fatty acids) in the
healthy diet of children and adolescents is well-known. A diet balanced in PUFA represented by
omega-3 and omega-6 is extremely important in neuro-cognitive and visual development and in
ensuring a long-term health status through anti-inflammatory, anti-allergic actions.
Fat foods are the main source of energy (fat provides 9 calories per gram), and they are
represented by triglycerides and cholesterol, which include fatty acids. Fatty acids are classified
into saturated, monounsaturated and polyunsaturated fatty acids [1].
Saturated fatty acids come from animal products, such as beef, pork and butter, and are
considered to have no beneficial health role (they are incriminated in the appearance of
atherogenesis). Fish oil that is considered to be of animal origin, but is classified as unsaturated
fatty acid, is excepted.
Unsaturated acids come from vegetable fats and are universally accepted to have a beneficial
effect on the health of the body. The exception is represented by the coconut oil and palm oil which
are classified as saturated fatty acids. Some of the polyunsaturated fatty acids cannot be synthesized
in the body, which is why they are called essential and must be brought into the body from food.
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Therefore, it is currently recommended, including in children, dietary supplementation with

PUFAs essential for harmonious growth and development, including omega-3 and omega-6 fatty
acids.
The omega-3 fatty acids represented by the fatty acid’s alpha-linolenic acid – ALA,
eicosapentaenoic acid – EPA, docosahexaenoic acid – DHA have anti-inflammatory effects and
neuronal protective functions [2]. Also, DHA is a constituent of the brain tissue and the optic nerve,
and therefore, even during intrauterine life and later, during childhood and adolescence, plays a
neuro-protective role in the optimal functioning of the visual function. Sources of omega-3 fatty
acids are: fish oil (tuna, mackerel, sardines, herring, herring), vegetable oils (in soybeans, canola).
The omega-3 fatty acids of nutritional importance are ALA, EPA and DHA [3, 4].
Omega-6 fatty acids included linoleic acid, γ-linolenic acid and arachidonic acid (AA). Linoleic
acid, the most common omega-6 acid in daily diet, has a role in lowering LDL cholesterol and in
AA synthesis that is found in large quantities in the vascular endothelium. Omega-6 fatty acids are
found in the oil obtained from grape seeds, corn, soy, sunflower and cotton.
Omega-9 fatty acids are oleic acids and over 80% of olive oil is composed of these fatty acids.
They are also found in lard, palm oil and sesame oil.
Because they are essential fatty acids, the daily diet, whether we are talking about the child or
adult, must contain PUFAs in the optimal amount. In particular, we know the beneficial health
roles of EPA and DHA, which are substances that are recognized to have the functionality of
omega-3 fatty acids. Administration of DHA to children with familial hyperlipidaemia has been
shown to increase the elasticity of vascular endothelium and thus to prevent progression of
evolution to the onset of coronary artery disease [4, 5].
Being major components of the brain and the retina, PUFAs should be administered from child
to adult, playing an important role both in brain growth and development as well as in the
prevention of degenerative neurological diseases [6].
The anti-inflammatory role of PUFA is due to the decrease in AA level, which is associated
with the suppression of inflammatory phenomena. Thus, it has been observed that the omega-3
fatty acid intake produces a lower level of prostaglandin compared to the administration of omega-
6 fatty acids [7]. It has also been observed that neutrophils secrete inflammatory mediators that
control and suppress inflammation using polyunsaturated fatty acids as precursors, consisting of:
lipoxin (derived from AA), resolving (derived from EPA and DHA) and epi-lipoxin [8, 9].
Generally, omega-3 fatty acids have anti-inflammatory, antithrombotic and neuroprotective
effects, while omega-6 fatty acids tend to maintain inflammatory phenomena [10]. Thus, the
increase in interleukin-1 (IL-1) synthesis has been associated with depression, dementia, cancer,
and autoimmune diseases (arthritis, lupus, Crohn's disease, ulcerative colitis) being associated with
increased leukotriene synthesis and inflammation precursors, these being derived from omega-6
fatty acids. It has been observed that the administration of EPA and DHA determined in these
conditions the improvement in clinical manifestations with decreasing anti-inflammatory
medication. Therefore, the predominant use of omega-3 fatty acids is recommended compared to
omega-6 [11]. Omega-3 fatty acids may improve the manifestations of Alzheimer’s disease by
increasing clearance of amyloid-β peptide, neurotrophic and neuroprotective factors, and by anti-
inflammatory effects [2].
Omega-3 fatty acids are essential for the harmonious development and health of children. It has
been observed that in infants who received high-DHA milk formula there was superior
coordination between eyes and hands, concentration and communication skills, higher scores were
recorded in intelligence tests. Also, long-chain PUFA (LC-PUFA) administration during
pregnancy reduced the frequency of premature birth, reduced the incidence of bronchial asthma in
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children [12]. In premature infants, omega-3-enriched formulas have helped to improve growth
and brain development. The phospholipid cells in the cerebral cortex and retina are rich in DHA,
so, especially this fatty acid plays an important role. Furthermore, breast milk is the ideal source
of omega-3, and its quality is largely affected by the foods the mother consumes [13]. Regarding
the duration of administration of PUFA in order to obtain clinical benefits, it has been shown that
for visual development, continuous intake up to 12 months is beneficial.
Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents.
Clinical and biochemical evidence suggests that deficiencies of omega-3 fatty acids could be
related to ADHD [14]. However, literature data is contradictory in the administration of fish oil as
a medication and behavioural improvement, the decrease in hyperactivity and the increase in
concentration capacity [15]. Thus, further studies are needed.
For an optimal intake of DHA and EPA in healthy functional food, a daily dose of 0.5-2 g was
proposed, taking into account the FDA's (Food and Drug Administration) suggestions not to exceed
3 g. This dose represents the level that can be obtained by weekly consumption of 2 fish of the
mackerel species. For patients with coronary artery disease, the American Heart Association
(AHA) recommends daily intake of 1g of EPA and DHA obtained from fish consumption or
medications administered according to medical recommendations. For pregnant or lactating
women, at least 200 mg of DHA/day was recommended to help the cerebral development of the
fetus and of new-borns. Regarding the consumption of omega-6 fatty acids, it is recommended for
the ingestion of linoleic acid to be about 2% of the total daily calories. Because omega-3 and
omega-6 compete, it is important to maintain an optimal intake ratio between the two, regardless
of whether they come from food or medication. The World Health Organization (WHO)
recommends a 5-10: 1 ratio (omega3: omega6) [15].
When PUFAs are administered to children, studies are inadequate as to the type, amount and
duration of administration of PUFAs. Many of the powdered formulas currently on the market
contain omega-3 fatty acids, but the effective level for children has not been established with
certainty. For young children, consumption of less than 60 g of fish per week is recommended,
taking into account the potential risk of environmental contamination, and recommends that tablets
of fish oil should not be administered without the doctor’s advice. Regarding the recommended
dose of omega-3 fatty acids in infants, WHO recommends 400 mg for 10 kg body weight, and
ISSFAL – 350-750 mg/10 kg bodyweight. The recommended intake of omega-3 and omega-6
according to age are represented in Tables 1 and 2 [16, 17, 18].
Table 1. The recommended intake of omega-3

Male Female
Age Source
(g/day) (g/day)
Infants (months)
0-6 ALA, EPA, DHA 0.5 0.5
7-12 ALA, EPA, DHA 0.5 0.5
Children (years)
1-3 ALA 0.7 0.7
4-8 ALA 0.9 0.9
9-13 ALA 1.2 1
Adolescents (years)
14-18 ALA 1.6 1.1
ALA: α-linoleic acid, EPA: eicosapentaenoic acid, DHA: docosahexaenoic acid [15]
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Table 2. The recommended intake of omega-6

Male Female
Age Source
(g/day) (g/day)
Infants (months)
0-6 Omega-6 PUFA 4.4 4.4
7-12 Omega-6 PUFA 4.6 4.6
Children (years)
1-3 LA 7 7
4-8 LA 10 10
9-13 LA 12 10
Adolescents (years)
14-18 LA 16 11
LA: linoleic acid [16]
But, in some situations, unsaturated fatty acids can have unhealthy roles. Excessive
administration of unsaturated fatty acids may affect the immune system, increase the risk of heart
disease, arrhythmias and stroke. Consumption for several months of fish oil must be doubled by
vitamin E (antioxidant) and may cause vitamin A or D toxicity.
Omega-3 fatty acids can be safely administered for a long time, but the FDA recommends not
to exceed 3 g/day of omega-3 fatty acids derived from fish oil. There is no obvious evidence of
benefits in infants if the mother consumes omega-3 fatty acids during pregnancy or lactation.
During pregnancy, increased intake of DHA contributes to weight gain at birth, but there is a
risk of bleeding. Administration of unsaturated fatty acids to pregnant women and women who are
breastfeeding requires caution because heavy metals (e.g., mercury and lead), dioxin and
polychlorinated biphenyl compounds accumulated in fish due to contamination of the marine
environment may lead to adverse effects to the fetus. As the mercury accumulates in fish, it would
be safer to administer fish oil if it is well refined [16].
In conclusion, PUFAs are essential fatty acids with multiple roles in the body. For children, they
have proven effective ever since intrauterine life through optimal brain development, decreased
preterm births, and subsequently a reduction in the incidence of neurologic and neuro-
compartmental disorders. PUFA supplementation may reduce inattention, hyperactivity and
impulsivity in children. However, some additional mentions regarding PUFAs consumption must
be made. There is no clear evidence of the duration of administration or the dose to be administered
to children, this further explains why new studies should be carried out in the future. Because of
the beneficial effects on health, diet supplementation with omega-3 fatty acids are recommended
compared with the omega-6 ones. It is important to take into account both the benefits and the risks
of administering them on long time.
REFERENCES
1. Swanson, D., Block, R., Mousa, S.A. (2012) Omega-3 Fatty Acids EPA and DHA: Health Benefits
Throughout Life. Adv Nutr. 3(1), pp. 1-7.
2. Yanai, H. (2017) Effects of N-3 Polyunsaturated Fatty Acids on Dementia. J Clin Med Res. 9(1): pp. 1-9.
3. Dunsta, J.A., Mitoulas, L.R., Dixon, G., Doherty, D.A., Hartmann, P.E., Simmer, K., Prescott, S.L. (2007)
The effects of fish oil supplementation in pregnancy on breast milk fatty acid composition over the course of
lactation: a randomized controlled trial. Pediatr Res. 62, pp. 689-94.
4. Judge, M.P., Harel, O., Lammi-Keefe, C.J. (2007) Maternal consumption of a docosahexaenoic acid-
containing functional food during pregnancy: benefit for infant performance on problem-solving but not on
recognition memory tasks at age 9 mo. Am J Clin Nutr. 85, pp. 1572-7.
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5. Kagawa, Y., Nishizawa, M., Suzuki, M., Miyatake, T., Hamamoto, T., Goto, K. (1982) Eicosapolyenoic acids
of serum lipids of Japanese islanders with low incidence of cardiovascular diseases. J Nutr Sci Vitaminol. 28,
pp. 441-53.
6. Chiu, C.C., Su, K.P., Cheng, T.C., Liu, H.C., Chang, C.J., Dewey, M.E., Stewart, R., Huang, S.Y. (2008) The
effects of omega-3 fatty acids monotherapy in Alzheimer’s disease and mild cognitive impairment: a
preliminary randomized double-blind placebo-controlled study. Prog Neuropsychopharmacol Biol
Psychiatry. 32, pp. 1538-44.
7. Makrides, M., Gibson, R.A., McPhee, A.J., Yelland, L., Quinlivan, J., Ryan, P. (2010) Effect of DHA
supplementation during pregnancy on maternal depression and neurodevelopment of young children: a
randomized controlled trial. JAMA. 304, pp. 1675-83.
8. Bloomer, R.J., Larson, D.E., Fisher-Wellman, K.H., Galpin, A.J., Schilling, B.K. (2009) Effect of
eicosapentaenoic and docosahexaenoic acid on resting and exercise-induced inflammatory and oxidative
stress biomarkers: a randomized, placebo controlled, cross-over study. Lipids Health Dis. 8, p. 36.
9. Serhan, C.N. (2005) Novel omega 3-derived local mediators in anti-inflammation and resolution. Pharmacol
Ther. 105, pp. 7-21.
10. Micallef, M.A., Garg, M.L. (2009) Anti-inflammatory and cardioprotective effects of n-3 polyunsaturated
fatty acids and plant sterols in hyperlipidaemic individuals. Atherosclerosis. 204, pp. 76-82.
11. Simopoulos, AP. (2002) Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 21,
pp. 495-505.
12. Furuhjelm, C., Warstedt, K., Larsson, J., Fredriksson, M., Bottcher, M.F., Falth-Magnusson, K., Duchen, K.
(2009) Fish oil supplementation in pregnancy and lactation may decrease the risk of infant allergy. Acta
Paediatr. 98, pp. 1461-7.
13. Decsi, T. (2009) Effects of supplementing LCPUFA to the diet of pregnant women: data from RCT. Adv Exp
Med Biol. 646, pp. 65-9.
14. Gillies, D., Sinn, JKh., Lad, SS., Leach, MJ., Ross, MJ. (2012) Polyunsaturated fatty acids (PUFA) for
attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev.
(7):CD007986.
15. Trumbo, P., Schlicker, S., Yates, A.A., (2002) Food and Nutrition Board of the Institute of Medicine, The
National Academies. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol,
protein and amino acids. J Am Diet Assoc. 102, pp. 1621-30.
16. Lee, Ji-Hyuk. (2013) Polyunsaturated Fatty Acids in Children. Pediatr Gastroenterol Hepatol Nutr. 16(3), pp.
153-61.
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Supraclavicular and Cervical Lymph Node Metastases having

Cervical Cancer as Starting Point. Case Presentation
PÂSLARU Ana-Maria1, NICULEȚ Elena1*, REBEGEA Laura2, TUTUNARU

Dana3,
CIUBARĂ Anamaria4
1 PhD-c “Dunărea de Jos” University, Faculty of Medicine and Pharmacy, Galați, (ROMANIA)
2 Medical Oncology Department, “Dunărea de Jos” University, Faculty of Medicine and Pharmacy, Galați, (ROMANIA)
3 Department of Morphological Sciences, “Dunărea de Jos” University, Faculty of Medicine and Pharmacy, Galați, (ROMANIA)
4 Psychiatry Department, “Dunărea de Jos” University, Faculty of Medicine and Pharmacy, Galați, (ROMANIA)
* Corresponding author: Niculeț Elena
Email: helena_badiu@yahoo.com
Abstract
Introduction
Cervical cancer is the fourth most frequently found cancer among women worldwide. Numerous
studies have underlined that persistent infection with human papilloma virus is the most important
risk factor, two strains of the same virus – 16 and 18 being responsible for approximately 70% of
the cases. Cervical cancer rarely metastasizes in the cervical lymph nodes and this indicates a poor
prognosis. Literature data reports an incidence for left supraclavicular M1LYm of 0.1-1.5%.
Material and Method

We bring attention to the case of a 44-year-old patient from the rural area that was diagnosed in
January 2019 with stage IIIB cervical cancer, represented morphologically by a poorly
differentiated squamous cell carcinoma. When admitted, the patient presented clinically with
vaginal haemorrhage, intense abdominal and pelvic pain, fatigue, adynamia, important weight loss.
The physiological personal history revealed nine pregnancies, having the first one when she was
16 years old. After pretherapeutic evaluation, the multidisciplinary committee decides performing
simultaneous radio-chemotherapy with platinum salts. During the second week of treatment
clinical examination disclosed left cervical and supraclavicular adenopathies, both of them
documented through imaging evaluation. Lymph node biopsy is done and its histopathological
aspect, correlated with the immunohistochemistry profile supports the diagnosis of poorly
differentiated squamous cell carcinoma lymph node metastasis. The initial treatment scheme is
maintained, the patient being discharged with clinical remission of cervical and supraclavicular
lymph node metastasis.
Conclusions
The peculiarity of the case is determined by the distant metastases in the left cervical and
supraclavicular lymph nodes, a rare finding during treatment, which was associated with a poor
prognosis; in this case treatment was done for palliative purposes. Rapid diagnosis is the main
factor that conditions the therapeutic results and chances for healing.
Keywords: Cervix, treatment, metastasis, supraclavicular lymph nodes
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Introduction
According to estimations made by the World Health Organization (WHO) in 2018, cervical
cancer is the fourth cause of malignancy among female patients worldwide. In the European Union,
Romania occupies the first place in regards to cervical cancer death rates – 14,2 to 100.000 women.
[1]
Many studies have revealed that certain strains of the human papilloma virus (HPV) are
responsible for cervical cancer development. This virus is also frequently associated with other
types of cancer: vulvar, vaginal, penile, oropharyngeal, anal. Approximately 120 HPV genotypes
have been discovered until now, 15 of these being involved in cervical cancer development. [2, 3]
Two strains – 16 and 18 are incriminated in the development of almost 70% of cancers. [4]
Among the risk factors for HPV infection there are: early sexual intercourse initiation, multiple
sexual partners, poor hygiene, multiparity. Clinically, cervical cancer is asymptomatic in early
stages. When vaginal bleeding occurs (the most frequent symptom) it is possible that the malignant
cells have already spread. Lymph node status is a prognostic factor of high value, the lymph node
spread being associated with a poor prognosis. [5, 6]
Material and Method
We present the case of a 44-year-old patient from the rural area diagnosed in January 2019 with
cervical cancer. The first admission is in the Gynaecology Department. When admitted, the patient
presented clinically vaginal haemorrhage, intense abdominal and pelvic pain, asthenia, adynamia,
important weight loss. From her physiological personal history, we notice 9 pregnancies, the first
one when she was 16 years old, without significant pathological history. After the gynaecology
consult a biopsy is taken from an ulcerated and vegetate exocervical mass. The pathology report
made the diagnosis of poorly differentiated squamous cell carcinoma. At gross inspection, the
cervical squamous cell carcinoma reveals an exophytic, red, friable, ulcerated lesion. On cut
surface, the tumour is whitish-grey, with areas of haemorrhage and/or necrosis.
Microscopic examination classifies squamous cell carcinoma in two categories: keratinizing or
non-keratinizing. The patient presented the keratinizing variant, which is made up of sheets or nests
of polygonal cells with intercellular bridges (desmozomes) and keratin pearl formation. The
neoplastic squamous cell has large, hyperchromatic nuclei with coarse chromatin, the nuclear and
cellular pleomorphism being variable. Concerning the degree of differentiation, the pleomorphism
of the tumour with pseudo-glandular structures and <75% undifferentiated structures (Fig. 1.) and
<25% keratinization allowed for it to be classified as a poorly differentiated squamous cell
carcinoma (G3).
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Fig. 1. Poorly differentiated squamous cell carcinoma (G3). Pseudo glandular area. H&Ex400
In February 2019 the patient is directed to the Radiotherapy Department for appropriate
specialized treatment. When admitted, the local exam reveals a lower third smooth walled vagina
cervix with an ulcerative-vegetant mass which measured 4/4 cm and haemorrhaged spontaneously
and by valve examination, absent vaginal pouches, enlarged uterine corpus with low mobility and
bilateral parameter infiltration that reached the pelvic excavation wall. Laboratory examination
bring attention to the tutor markers, with values for cancer antigen (CA) 125 of 483 U/mL, CA-
19.9 of 2710 U/mL, carcinoembryonic antigen (CEA) of 72,8 U/mL. We do not have available data
for the squamous cell carcinoma antigen (SCCA). Thoracoabdominal and pelvic computed
tomography (CT) did not reveal malignant pelvic adenopathy; the liver, pancreas and lungs did not
have any discernible pathological alterations. The patient fell into the IIIB stage (T3bN0M0).
After pretherapy evaluation, the multidisciplinary committee decides for concomitant radio-
chemotherapy treatment, along with brachytherapy. It is well tolerated by the patient, with no
digestive or haematological toxicity. During the second week of treatment, clinical examination
revealed left cervical and supraclavicular adenopathies. In this case the patient is evaluated through
imaging studies which documented the presence of left cervical and supraclavicular lymph node
enlargement, of a right renal, poorly iodophilic, heterogeneous image measuring a diameter of 16,5
mm (Fig. 2), a globular cervix measuring 33 mm (Fig. 2), with no retroperitoneal adenopathies and
intense disk and bone structure alterations located at the level of the 4th and 5th cervical vertebrae.
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(a) (b)
Fig. 2. CT scan February 2019 – (a) a right renal, poorly iodophilic, heterogeneous image,
and (b) globular cervix – 33mm
The patient is transferred to the otorhinolaryngology department (ENT) where the involved
lymph nodes are biopsied. The pathology report reveals that the lymph nodes present a malignant,
anaplastic cell proliferation. By immunohistochemistry examination CK7 and p63 are positive in
the neoplastic cells, CK20 and ER are negative and Ki-67 is present in 80% of cells. In conclusion,
the histopathology aspect correlated with the immunohistochemistry profile reveals the diagnosis
of poorly differentiated (G3) squamous cell carcinoma lymph node metastasis. Due to the similar
histological aspect and degree of differentiation, we considered the left cervical and supraclavicular
metastasis as having the cervix as onset.
The initial weekly treatment with platinum salts and cisplatin 40 mg/m2, respectively, along
with external radiotherapy (RTE) is continued; the total dose (TD) is 46 Gy/23 fractions, with a
dose/fr equal to 200 cGy. The patient is compliant and responds well to therapy, so that when
discharged the cervical and supraclavicular adenopathies are in full clinical remission. She is
redirected to another Radiotherapy center in order to complete her therapy dose with brachytherapy
which she does not do due to personal reasons. We mention the lack of brachytherapy in our
treatment center.
The patient continues cancer treatment with 2 series of carboplatin and topotecan. She develops
moderate vomiting, first degree anaemia and leukopenia which is corrected with granulocyte
growth factors and cortisone formulas. During the treatment course, the patient benefited from
psychological counselling.
In July 2019 she is admitted to the Radiotherapy Department for revaluation. Clinically, the
patient has no symptoms, with a performance index (PI) of 0. The haematology labs highlight the
presence of a second-degree anaemia with a haemoglobin value of 9,7 g/dL and a haematocrit of
28,80%, erythrocyte sedimentation rate of 40 mm/h and hypocalcaemia. The local gynaecological
examination reveals the cervix without a macroscopically evident neoplastic mass, vaginal
telangiectasia and supple parameters. A cytology exam is done and the Papanicolaou stained
vaginal smear reveals post-radiotherapy alterations with large, atypical squamous cells, having a
two-tone cytoplasm, finely granular chromatin, conspicuous nucleoli and irregular membrane,
some with keratohyalin granules or with nuclear and/or cytoplasmic vacuoles. The presence of a
predominantly neutrophilic granulocytic inflammatory infiltrate is associated, with cytolysis and
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mature and immature squamous metaplasia (Fig. 3). These aspects suggest a chronic
postradiotherapy change, the data described needing clinical and laboratory correlations.
Fig. 3. Atypical squamous cells of undetermined significance. Changes suggestive for chronic postradiotherapy
period. Papanicolaou stain x400
Contrast soft tissue cervical, thoraco-abdominal and pelvic computed tomography reveals 8 mm
left cervical lymph nodes, normal-sized kidneys with physiological secretion and excretion, no
retroperitoneal lymph node enlargement and no discernible lung and liver pathological changes.
The cervix presents a homogenous, iodophil image that is smaller than what was previously
found at CT examination (Fig. 4).
(a) (b)
Fig. 4. CT scan July 2019 – (a) Heterogeneous cervical image
and (b) normal sized kidney with physiological secretion and excretion
The next post-therapy check-up is scheduled in three months. Post-therapeutic monitoring

includes clinical examination and gynaecological consults once every 3 to 6 months in the first 2
years and 6 to 12 months in the third to the fifth-year post-treatment.
Discussions
The International Federation of Gynaecology and Obstetrics (FIGO) describes five stages of
cervical cancer. Stage 0 and I are preclinical ones in which the diagnosis is made by cytology
examination; stages II, III and IV are accompanied by clinical signs and are associated with
malignant invasion [8, 9].
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Concomitant radiotherapy and chemotherapy for patients with stage IB2 bulky – IV is the
standard treatment recommended by the NCCN and ESMO guidelines. Clinical trials highlight the
disease-free survival (DFS) and overall survival (OS) as being increased for concomitant radio-
chemotherapy versus radiotherapy alone. [10]
Results are contradictory concerning administering induction chemotherapy anterior to
radiotherapy. Life expectancy is correlated with the tumour stage at diagnosis, stage 0 having a 5-
year survival rate of 100%, while stage IV reaching a ratio of only 7%. [9]
Lymph node involvement is an important prognostic factor and has a huge impact in the
subsequent therapeutic conduct. [6] In a report by Peters et al., [8], enhanced survival is mentioned
by the fact that patients with involved lymph nodes who underwent treatment with cisplatin
concomitant with pelvic radiation, have had a far better response than those who benefitted only
from RTE. For patients who were initially diagnosed with lymph node metastases, chemotherapy
with platinum salts seems to have an effectively positive result [11], many studies continuing to
report favourable results, contrary to the multiple severe acute haematological and gastrointestinal
toxicities. [12-13, 14, 15]
The most frequent lymph node groups involved in the metastatic process are: obturator,
hypogastric, iliac artery bifurcation and sacral lymph nodes. In 30% of cases the pelvic lymph
nodes can be involved without the presence of parameter invasion, the survival rate being 71%.
[16]
In a study done by Shandong Cancer Hospital it was revealed that the most common site for
pelvic lymph node metastasis are the obturators with a ratio of 17,6%, followed by external and
internal iliac lymph nodes 13,4%, common iliac 3,6%, para-aortic 1,7% and presacral lymph nodes
0,6%. [17]
Cervical lymph nodes are the most frequent metastatic site for head and neck tumours. Cervical
and supraclavicular lymph nodes are rarely found in current practice. Literature data report a ratio
of secondary supraclavicular lymph node involvement of 0.1%-1.5%. Patients with involved
supraclavicular lymph nodes treated with chemotherapy have a reported 3-year and 5-year survival
rate of 16,5%.
However, occult supraclavicular lymph node metastases have been identified by FDG-PET in
8% of patients (14 of 186).
Supportive psychotherapy must focus on solutions, and in all medical cases, supportive groups
may be efficient by sharing individual experiences, such as patient groups with the same diagnosis
or patient groups with the same therapeutic sequence. [18]
Conclusions
Although screening programs exist, cervical cancer is still diagnosed in advanced stages,
although it benefits from double prevention, both through regular testing and through vaccination.
The main aim of the treatment in the advanced stages of the disease is palliation and reaching a
minimal toxicity and complication risk. [9]
The peculiarity of the case resides in the distant metastasis to the cervical and supraclavicular
lymph nodes, a rare finding during treatment that is associated with a poor prognosis.
In this case we notice the full remission of the secondary left cervical and supraclavicular lymph
node involvement. Early diagnosis is the main factor which conditions the therapeutic results and
chances for survival.
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A big part of the current research is aimed at molecular detection of cervical cancer precursors;
this should overcome many of the deficiencies associated with screening and cervical cytology
programs. [8]
REFERENCES
1. European Cancer Observatory,

http://eco.iarc.fr/EUCAN/CancerOne.aspx?Cancer=25&Gender=2,
2. Bruni L, et al., “ICO Information Centre on HPV and Cancer (HPV Information Centre). Human
Papillomavirus and Related Diseases in Romania”. Summary Report 2016-02-26.
3. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases.
Chapter 11, Human Papillomavirus Hamborsky J, Kroger A, Wolfe S, eds. 13 th ed. Washington D.C. Public
Health Foundation, 2015.
http://www.cdc.gov/vaccines/pubs/pinkbook/index.html
4. Castellsagué X, et al., “HPV vaccination against cervical cancer in women above 25 years of age: key
considerations and current perspectives”, Gynecol. Oncol (2009), doi: 10.1016/j.ygyno.2009.09.021
5. deVita Jr. VT, Samuel Hellman S, Rosenberg SA – Cancer: Principles and Practice of Oncology, 5 th Ed,
Lippincott – Raven, 1997, pp. 1433-1456.
6. Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread
patterns of endometrial cancer. A Gynaecologic Oncology Group Study. A Gynaecologic Oncology Group
Study. Cancer. 1987; 60(Suppl. 8): pp. 2035-41. [PubMed] [Google Scholar]
7. Denny L, Quinn M, Sankaranarayanan R. Screening for cervical cancer in developing countries. Vaccine
24(S3): pp. 71-77, 2006.
8. Peters W, Liu PY, Barrett RJ, et al., Concurrent chemotherapy and pelvic radiation therapy composed with
pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early – stage cancer of the
cervix. J Clin Oncol. 2000; 18(8): pp. 1606-1613.
9. Bhatla N, Berek J, Cuello M, et al., New revised FIGO staging of cervical cancer (2018). Abstract S020.2.
Presented at the FIGO XXII World Congress of Gynaecology and Obstetrics. Rio de Janeiro, Brazil, October
14-19, 2018. Int J Gynecol. Obstet. 2018; 143 (Suppl.3): DOI: 10.1002/ijgo.12584
10. Stryker JA, Mortel R. Survival following extended field irradiation in carcinoma of cervix metastatic to para-
aortic lymph nodes. Gynecol. Oncol. 2000; 79: pp. 399-405.
11. Kim YS, Kim JH, Ahn SD, Lee SW, Shin SS, Nam JH, et al. High-doseextended-field irradiation and high-
dose-rate brachytherapy with concurrent chemotherapy for cervical cancer with positive para-aortic lymph
nodes. IntJ Radiat Oncol Biol Phys. 2009; 74: pp. 1522-8.
12. Kazumoto T, Kato S, Yokota H, Hasumi Y, Kino N, Horie K, et al., Is a low dose of concomitant
chemotherapy with extended-field radiotherapy acceptable as an efficient treatment for cervical cancer
patients with metastases to the para-aortic lymph nodes? Int J Gynecol. Cancer. 2011; 21: pp. 1465-71.
13. Kim JY, Kim JY, Kim JH, Yoon MS, Kim J, Kim YS. Curative chemoradiotherapy in patients with stage
IVB cervical cancer presenting with paraaortic and left supraclavicular lymph node metastases. Int J Radiat
Oncol Biol Phys. 2012; 84: pp. 741-7.
14. Small Jr W, Winter K, Levenback C, Iyer R, Hymes SR, Jhingran A, et al., Extended-field irradiation and
intracavitary brachytherapy combined with cisplatin and amifostine for cervical cancer with positive para-
aortic or high common iliac lymph nodes: results of arm II of Radiation Therapy Oncology Group (RTOG)
0116. Int J Gynecol Cancer. 2011; 21: pp. 1266-75.
15. http://doctorate.ulbsibiu.ro Rezumatul tezei de doctorat pentru obţinerea titlului de doctor în ştiinţe medicale
MODALITĂȚI TERAPEUTICE CHIRURGICALE ÎN CANCERUL DE COL UTERINConducător
științific: Prof.Univ.Dr. Stretean Adrian.
16. Xinglan Li, Yueju Yin, Xuigui Sheng, Xiaoyun Han, Chunhua Lu, Xiang Wang. Distribution pattern of lymph
node metastases and its implication in individualized radiotherapeutic clinical target volume delineation of
regional lymph nodes in patients with stage IA to IIA cervical cancer. Radiat Oncology 2015
17. Psycho-Oncology Support. Laura Rebegea, Dorel Firescu, Ginel Baciu, Anamaria Ciubara. BRAIN. Broad
Research in Artificial Intelligence and Neuroscience. Vol 10 (2019); pp. 77-88.
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Polyradiculoneuritis in an Adolescent after Acute Pneumonic
JESCU Teodora1, MIRON Ingrith2, LUPU Vasile Valeriu3*, MOISA Stefana4,

POSTOLACHE Anca5, MIRON Oana Tatiana6, LUPU Ancuta7
1 Pediatrics, “Grigore T Popa” University of Medicine and Pharmacy, Iași, ROMANIA
6 Pneumolgy Hospital, Iasi, Romania
* Corresponding author: LUPU Vasile Valeriu
Emails: teodorajescu@gmail.com, lucmir@yahoo.com, valeriulupu@yahoo.com, stephaniemed@yahoo.com,

ancap93@gmail.com, ingridmiron@hotmail.com, anca_ign@yahoo.com
Abstract
Polyradiculoneuritis or Guillan Barré’s Syndrome is the most common cause of acute and
subacute generalized paralysis, which is likely to occur at any age. We present the case of a 17-
year-old adolescent who was admitted to our clinic for swallowing and phonation disorders,
evolving into acute respiratory insufficiency (which required orotracheal intubation and ventilatory
support), hypotonia in the upper and lower limbs, and globally-decreased osteotendinous reflexes,
abolished in the upper limbs. The thoraco-abdominal X-ray and the chest CT revealed lower
respiratory infection, and the neurological clinical examination and the lumbar puncture with
albino-cytological dissociation raised the suspicion of polyradiculoneuritis. Therapy with
intravenous immunoglobulin resulted in the improvement of the motor deficiency, but without the
possibility to detubate the patient. Following 2 sessions of plasmapheresis with 20% human
albumin, significant improvement of the neurological deficiency was seen and spontaneous
breathing was resumed, the patient regaining full muscle strength.
Keywords: polyradiculoneuritis, Guillan Barré’s Syndrome, intravenous immunoglobulins, plasmapheresis,
swallowing disorders, pneumonia
Background
Acute polyradiculoneuritis is an immune-mediated inflammatory polyneuropathy causing acute

and diffuse demyelinating lesions in the nerves of the peripheral nervous system (1). In
approximately 60% of cases, it occurs after a respiratory infection (most commonly caused by
Mycoplasma pneumoniae) or after a gastrointestinal infection (Campylobacter jejuni, Helicobacter
pylori), with neurological symptoms occurring after 1-3 weeks. It is a non-epidemic and non-
seasonal disease, with a distribution women/man of 1.5/1. The earliest symptoms are paraesthesia
of the lower limbs, after which the progressive, relatively symmetrical, ascending motor deficit is
installed, affecting the intercostal muscles and the neck (2). The clinical picture raises the suspicion
of polyradiculoneuritis (also known as Guillan Barré’s Syndrome), and confirmation is made by
examining cerebrospinal fluid and by needle electromyography. The specific therapy requires
admission in intensive care unit for surveillance, because the ascending paralysis can rapidly
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develop into acute respiratory failure; without orotracheal intubation and ventilation support it
leads to death. The therapy with the best results is the administration of intravenous
immunoglobulin 0.4 g/kg/day for 5 days. If this protocol is insufficient, plasmapheresis is another
option (3, 4, 5).
Case Presentation
An adolescent, age 17 years and 11 months, was admitted to our clinic for irritable dry cough,
39°C fever, weak voice, mixed dysphagia, loss of appetite, sialorrhea; these symptoms started a
week ago. At home he was treated with antibiotics, according to the recommendations of the family
doctor, but he cannot remember the name of the medicine. The patient came without a legal
companion, and the anamnesis was performed with difficulty due to major dysphonia and dyslexia.
The family medical history did not reveal significant pathological elements, and the personal
history shows that he was vaccinated according to the national regulations and that he did not
undergo any chronic therapies at home.
The clinical examination upon admission showed satisfactory general condition; the patient was
of normal weight, aware, cooperative, time and space oriented, facies with dark circles, pale skin,
loaded tongue, normal pulmonary sounds, weak voice, irritating cough and suprasternal retraction.
Laboratory tests were: leucocytosis (16.990/mm3) with neutrophilia (13.650/mm3), increased
inflammatory markers (ESR-33mm/h, Fibrinogen-531 mg/dl), hyposideremia (Iron-20 µg/dl),
hypocalcaemia (Ionic Calcium – 4 mg/dl) and the increase of the alkaline reserve (AR-33. 22
mmol/l).
Based on the clinical and paraclinical criteria, the diagnosis of acute supraglottic laryngitis was
established and we began the therapy with Ceftriaxone, hydrocortisone hemi succinate and
symptomatic medication.
During the second day of hospitalization, the patient’s condition worsened, with marked
sialorrhea and swallowing disorder, accentuated dyspnoea with polypnea, generalized retraction,
tachycardia, oxygen saturation being 84% in atmospheric air and 89% with oxygen source. ENT
examination was recommended, and the indirect laryngoscopy revealed the lack of oedema in the
epiglottis and salivary stasis in large quantity in the pyriform sinuses, thus discarding the diagnosis
of acute supraglottic laryngitis. The patient was admitted to Intensive Care and submitted to therapy
with Meropenem and Vancomycin, facial mask oxygen therapy and symptomatic medication. The
blood count showed an increase in leucocytosis and neutrophilia. Reactive protein C, initially
within normal limits, increased to 130 mg/l.
On the third day, due to the progressive deterioration of the general condition, anxiety and
suffocation under oxygen therapy, the patient was sedated and orotracheal intubation was applied,
increasing saturation from 82% with oxygen source to 92% after intubation. During the manoeuvre
the absence of the pharyngeal reflex was noted (following the direct stimulation of the pharynx
there was no feeling of nausea or vomiting, nor the contraction of the pharyngeal wall muscles).
Nasogastric tube, central venous catheter on the internal jugular vein, and urethro-bladder tube
were applied.
A number of additional paraclinical examinations were recommended for the diagnosis: sample
of tracheobronchial aspirate, nasal exudate, haemoculture, urine culture, coprocytogram and stool
culture, but all these do not lead to a specific etiological factor. Ac VHC, Ag HBs, Ac anti
Mycoplasma pneumoniae IgM, Ac anti Borrelia burgdorferi IgM, Ac anti Cytomegalovirus IgM,
Anti-HIV 1+2 were negative. Front-rear thoracic X-ray reveals a medium-intensity dull structure,
unclearly delimited, without the aerial bronchogram visible in the lower half of the left hemithorax,
with moderate attraction effect of the lateral intercostal areas (Fig. 1).
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Fig. 1. Thoraco-abdominal X-ray – dull structure unclearly delimited in the left hemithorax
CT examination revealed focal alveolar filling without aerial bronchogram, which contained
small aerial inclusions, with normal contrast of the vascular structures, visible at the level of the
lower left lobe, which moderately exerted a retractable effect on the fissure – atelectasis of the
lower left lobe. Small amount of left pleural fluid in basal rear area, ~ 5mm (Fig. 2, 3).
Fig. 2. Chest CT atelectasis of the lower left lobe Fig. 3. Left pleural fluid layer
For a final diagnosis, the tuberculin intra-dermo reaction was performed; after 72 hours, a
palpable dermal papilla appeared, uneven, with a diameter of approximately 15 mm. Tracheal
aspirate was negative, with no mycobacterial DNA. The patient continued to receive Vancomycin
and Meropenem, to which an anti-fungal was added. Significant amounts of purulent secretions
were aspirated from the oro-tracheal intubation tube. After 5 days of antibiotic therapy it was
decided to decrease the sedative dose and to detubate the patient, but it was found that the patient,
although aware and cooperative, could not resume the spontaneous breaths as the cough reflexes
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were absent, and the limb muscles were hypotonic. The patient also had facial paresis. Lumbar
puncture was performed, and the analysis of cerebrospinal fluid showed albumino-cytological
dissociation.
Following the neurological clinical examination, we found the global decrease of the
osteotendinous reflexes and the decrease of the muscular force predominantly in the upper limbs.
The suspicion of polyradiculoneuritis was raised, and for the precision of the diagnostic the
needle electromyography was recommended. The result suggested polyradiculoneuritis.
Intravenous human immunoglobulin treatment was initiated, 0. 4g/kg/day, for 5 days, with
improvement of motor deficiency, but with the impossibility of detubation due to persistent
respiratory failure. Subsequently, two sessions of plasmapheresis were performed, with 20%
human albumin, resulting in significant improvement of the neurological deficit. The patient was
detubated and spontaneous breathing, standing and walking were resumed. At 28 days after the
admission the patient was discharged with a very good general condition, with the diagnosis of
acute polyradiculoneuritis.
Discussions
Polyradiculoneuritis is the most common cause of acute or subacute paralysis. From the etio-
pathogenic point of view, primitive polyradiculoneuritis, which occurs in the absence of a
premonitory disorder, along with secondary polyradiculoneuritis developing in a pathological
context: infections (viral hepatitis B and C, cytomegalovirus, Epstein Barr’s virus, HIV,
Mycoplasma and Campylobacter), vaccinations (rabies, oral polio and conjugated
antimeningococci), surgery and blood transfusions (6). The pathogenesis is partially known, the
most plausible hypothesis being the occurrence of an autoimmune process. Acute demyelination
blocks the transmission of nerve impulses favouring the onset of clinical symptoms. When the
cause is cleared, the normal myelination process is resumed (7).
This case started with a respiratory infection in a patient with no significant personal history,
and about 10 days after the onset, swallowing and phonation disorders caused the adolescent to
come to the hospital.
Judging by the symptoms and the conclusions of clinical examination, several possible
diagnostics were considered initially: aspiration of foreign bodies, retropharyngeal/peritonsillar
abscess, acute supraglottic laryngitis. Although the patient had coughing and choking seizures, the
diagnostic of aspiration of foreign bodies was discarded after anamnesis. The
retropharyngeal/peritonsillar abscess occurs with sialorrhea, swallowing disorders and trismus, but
it doesn’t affect the voice, so this diagnosis was also discarded. Dysphagia, sialorrhea, suprasternal
retraction and weak voice were the main clinical manifestations that guided us towards the
diagnosis of acute supraglottic laryngitis. Saliva allows effective chewing, swallowing and
speaking. Also, saliva has antibacterial and antifungal properties, thus playing a protective role (8).
The patient’s condition aggravated progressively. The biological samples showed no specific
pathogens, and the lumbar puncture, after the sampling and analysis of the cerebrospinal fluid,
supported the diagnostic of polyradiculoneuritis. Although the clinical picture was atypical, lumbar
puncture and needle electromyography confirmed once more the diagnostic of Guillen Barré’s
Syndrome. The therapy with immunoglobulins was not sufficient for the detubation of the patient,
but after the two sessions of plasmapheresis, the patient resumed effective spontaneous breathing,
standing and walking, being discharged with very good general condition.
The peculiarity of our case is represented precisely by the onset of polyradiculoneuritis, by
affecting the bulbar cranial nerves, with swallowing and phonation disorders, being this a less
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common clinical picture. In the literature, the administration of immunoglobulins and

plasmapheresis are considered to have relatively equal benefits (2). The second peculiarity of the
case is the aggressiveness of the disease, the evolution being progressively aggravating despite the
administration of immunoglobulins, which required the addition of plasmapheresis. The pathology
is on its natural healing course. Our patient has completely regained muscle strength, but some
patients may be left with residual weakness. In about 7% of cases, children with
polyradiculoneuritis may have a recurrence of the disease or it may be chronic and taking the form
of chronic demyelinating inflammatory polyradiculoneuritis (9).
Also, cases of Guillan Barré’s Syndrome have been reported as having as a trigger factor the
implantation of an allergenic bone graft in oro-maxillofacial surgery. A 55-year-old patient
required restorative surgery for the completely edentulous and atrophic mandible and jaw. Bone
autograft from the left iliac crest combined with lyophilized allografts were used to restore the
thickness and height of the mandible and jaw, and postoperative evolution was favourable;
however, after 7 days, the patient experienced episodes of muscle weakness and paralysis of the
lower limbs, followed by respiratory insufficiency because the intercostal muscles were affected.
After the specific therapy, the muscle deficit was improved, the patient was left with no residual
paralysis or other neurological deficiencies (10, 11).
Conclusions
Polyradiculoneuritis or Guillan Barré’s Syndrome is a disorder of the nerve roots and peripheral
nerves, with possible extension to the cranial nerves, due to an extensive inflammatory process. In
most cases, with the help of appropriate therapy, the patients recover completely. The supportive
treatment is the admission to the Intensive Care Unit, and the pathogenic treatment involves
intravenous immunoglobulin and plasmapheresis.
REFERENCES
1. Korinthenberg R. Acute polyradiculoneuritis: Guillain-Barré syndrome. Handb Clin Neurol. 2013; 112: pp.
1157-62.
2. Mullings KR, Alleva JT, Hudgins TH. Rehabilitation of Guillain-Barré syndrome. Dis Mon. 2010 May. 56(5):
pp. 288-92.
3. Bersano A, Carpo M, Allaria S et al., Long-term disability and social status change after Guillain-Barré
syndrome. J Neurol. 2006 Feb. 253(2): pp. 214-8.
4. Hughes RA, Pritchard J, Hadden RD. Pharmacological treatment other than corticosteroids, intravenous
immunoglobulin and plasma exchange for Guillain-Barré syndrome. Cochrane Database Syst Rev. 2013 Feb
28. 2:CD008630.
5. Luo L. Principles of Neurology. Current Biology. 2008(18): pp. 842-843.
6. van Doorn PA, Ruts L, Jacobs BC. Clinical features, pathogenesis, and treatment of Guillain-Barré syndrome.
Lancet Neurol. 2008 Oct; 7(10): pp. 939-950.
7. Hauser SL, Josephson SA. Neurology in clinical medicine. 2013 ISBN: 978-0-07-181501-7.
8. Ignat A, Burlea M, Lupu VV, Paduraru G. Oral manifestations of gastroesophageal reflux disease in children.
RJOR. 2017; 3(9): pp. 40-43.
9. Kliegman R, Stanton B, Behrman RE et al. Nelson textbook of paediatrics. 2016.
10. Cicciù M, Herford AS, Bramanti E, Maiorana C. Guillain-Barré syndrome: Report of two rare clinical cases
occurring after allergenic bone grafting in oral maxillofacial surgery. Int J Clin Exp Pathol. 2015; 8(6): pp.
7614-6.
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Difficulties in the Therapeutic Management of Complicated

Pneumonia in Children
MIRON Oana2, IVANOV Anca1, MOCANU Adriana1, STÂRCEA Magdalena1*,

TRANDAFIR Laura1, MIRON Ingrith1
1 Emergency Children’s Hospital St Mary, Medical School, Iași (ROMANIA)
2 Pneumology Clinic, Clinical Hospital of Lung Diseases, Iași (ROMANIA)
* Corresponding author: Magdalena Stârcea
Email: magdabirm@yahoo.com
Abstract
Background
Pneumonia remains an important cause of morbidity and mortality at pediatric age (estimated
by UNICEF at 3 million child deaths per year worldwide). Although the ethiology of pneumonia
is well known, in many patients the exact pathogen is not identified after routine diagnostic workup.
We present three cases that were diagnosed and treated in our hospital for Pneumonia with
complications. The aim of this case series is to point out the challenges in diagnosing and managing
such diseases in children. The evolution of the three cases was difficult, all children needed ICU
care. Cultures collected for all of them were negative, probably secondary to the fact that they
received antibiotic treatment at home, before carrying out tests. Yet, after receiving broad spectrum
antibiotics and supportive treatment the evolution was favourable in the end.
Conclusion
Despite progresses that were made in the last century concerning the antibiotic treatment in
pneumonia there are still cases that develop severe complications that require multidisciplinary
approach.
Keywords: child, complicated pneumonia, antibiotics
Introduction
Pneumonia remains the leading cause of death in children under five worldwide. It accounts for
about 1.6 million deaths a year in this age group – 18% of all deaths among children under five.
(1, 2)
Even in present times pneumonia remains a public health problem because of its great morbidity
and mortality as well as high economic burden worldwide. (3, 4, 5, 6)
The majority of children are treated as outpatients and the proportion of children presenting to
the emergency department with pneumonia who are then hospitalized ranges from 19 to 69%.
Therefore, pneumonia remains an important cause of hospitalization among children in
developed countries. (7)
In the last two decades it has been described a growth trend of complicated pneumonia, despite
of declining rates of community acquired pneumonia in children. (1)
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The focus of this article is on complicated pneumonia which develops not only in children with
underlying diagnosis and a low immune status, but also in a small proportion of immunocompetent
children.
A child with community acquired pneumonia can develop both local and systemic
complications. Usually, local complications refer to pleural effusion/empyema, pericardial
effusion, lung abscess, necrotizing pneumonia and atelectasis. (4, 7, 8, 9)
The most common systemic complications are severe sepsis, acute respiratory distress
syndrome, syndrome of inappropriate antidiuretic hormone secretion, haemolytic uremic
syndrome, disseminated intravascular coagulation and secondary thrombocytosis. (2, 8, 9)
Case presentation
We present three cases of pneumonia with unusual evolution, that was not predicted by the
minimal symptoms from the onset.
Case 1
1 year and 9 months female, presented for fever, dyspnoea, productive cough, lack of appetite.
At admission she presented influenced status, extreme irritability to the examination, pale skin,
expiratory dyspnoea, expiratory grunting, increased respiratory rate (41 respiration per minute),
intercostal retraction, SaO2 (-) = 93%.
Blood tests showed: increased leukocyte number with predominant neutrophils, anaemia, low
iron level, positive inflammatory syndrome, negative nasal and pharyngeal exudate.
Chest X-ray showed medium intensity round opacity, bilateral perihilar interstitial infiltration,
more significant on the left lung, clear costo-diafragmatic sinuses.
Treatment and evolution: We started antibiotherapy with Ceftriaxone and Gentamicin and
symptomatic treatment with Hydrocortisone hemisuccinate, Acetylcysteine, nebulization and
intravenous hydration with favourable evolution (remission of fever, rare cough, but persistence of
dyspnoea).
In the third day of treatment we noticed important abdominal distention, worsening dyspnoea,
lack of stool of about 48 hours. Surgical consultation recommended simple abdominal radiography.
Abdominal X-ray description was suggestive for sub-occlusive syndrome. (Fig. 1)
Therefore, we have continued treatment only with ceftriaxone and intravenous rehydration, so
that the sub-occlusive syndrome was resolved, respiratory symptomatology also resolved, but the
child maintained discrete dyspnoea. Although, the child maintained influenced status, pale skin
and irritability.
In evolution, by repeating blood tests we found a minimal increase in leukocyte number and
neutrophils and erythrocyte sedimentation rate and C-reactive protein with really high values.
Thus, we’ve decided to change from Ceftriaxone to Piperacillin/Tazobactam. With this new
treatment the child had a good evolution both clinical and biological (inflammatory markers
decreased significantly). After 8 days with this new antibiotic treatment, the patient resumes
symptoms of productive cough, dyspnoea, wheeze and rhonchi across the left lung area. Repeated
blood tests showed an important increase of CRP. Repeating the X-ray, we saw a transparent lesion
of 35/24mm, circled by a 3mm peripheric opaque ring located in the posterior side of left-superior
lobe. (Fig. 2)
Considering the clinical and paraclinical evolution we have raised the assumption of
staphylococcal pneumonia. So, we’ve started treatment with Teicoplanin, Meropenem and
Metronidazole with good evolution.
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Control chest X-ray described mild interstital infiltrate of both lungs; two radiotransparent
lesions that appear to communicate on the superior located near heart.
The patient had a slow favourable evolution, being hospitalized for about 6 weeks.
Case 2
Female child, 8 years old, presented for fever and chest pain. The disease started 5 days before
presentation with fever, vomiting and semi-solid stools.
At admission the patient presented relatively good general status, afebrile, but she had dyspnoea,
diminished vesicular breath sounds at the base of right lung and dull percussion on the same side.
Blood test showed an increased number of leukocytes (37170/mmc) with predominance of
neutrophils (92%) and an important inflammatory syndrome (CRP=252mg/l). Chest x-ray at the
onset showed an opacity located on the upper right pulmonary lobe and presence of fluid in the
right costo-diafragmatic sinus (Fig. 4).
We’ve started the treatment with Ceftriaxone and Gentamicin with unfavourable evolution,
increasing chest pain and dyspnoea. Our second option was an association between
Piperacillin/Tazobactam without improvement of general state and maintaining of abnormal blood
tests.
Therefore, thoracic computed tomography was performed (Fig. 5, 6, 7). It revealed the presence
of right pyopneumothorax. In that case a pleural drainage was performed in association with large
spectrum antibiotic therapy (Meropenem, Linezolid, Metronidazole).
Seven days after the pleural drainage, another chest x-ray was performed. It revealed the
maintaining of a non-homogeneous opacity in medium 2/3 of the right hemithorax (Fig. 8). Thus,
a video-assisted thoracoscopy (VAT) pleuropulmonary decortication was done (Fig. 9). A
subsequent chest x-ray revealed an ameliorated image (Fig. 10). Post-operatory evolution was
slowly favourable despite the association between large spectrum antibiotic therapy and systemic
antifungal therapy. The patient also needed supportive with rehydration perfusion, immunotherapy
and blood transfusion for about one month.
Case 3
An 8 years old female child presented for fever, sore throat, dysphagia and irritative cough. The
symptoms started 3 days before the admission.
The medical history of the patient revealed that she has been diagnosed with acute myeloid
leukaemia (positive FLT3-ITD mutation – associated with unfavourable prognosis), in remission
for 1,5 years. At admission she presented influenced general status, pale skin, clinical aspect of
ulcero-necrotic tonsillitis, fever, irritative cough, vesicular breath sounds, without abnormal breath
sounds. Blood tests revealed an increased number of leukocytes (34870/mmc) with predominance
of neutrophils (80%) and an important inflammatory syndrome (CRP=126mg/l). Bone marrow
aspirate revealed late medullary relapse (42% blasts). In that case we’ve started broad spectrum
antibiotics (Meropenem, Ciprofloxacin and Metronidazole) that determined the relieving of acute
symptoms. After that, chemotherapy was started with low dose cytarabine. In the 11th day of
hospitalization the patient developed high fever, shortness of breath, productive cough and severe
post-chemotherapic neutropenia (20/mmc). Chest x-ray was consistent for bronchopneumonia.
(Fig. 11) Therefore, she received treatment with Linezolid and Teicoplanin for the next 10 days.
Despite of this therapy, the girl had no clinical improvement and maintained the respiratory
symptoms. For the next 5 days she received Linezolid, Teicoplanin and Fluconazole with poor
clinical and radiologic evolution. For the next 7 days we’ve changed Fluconazole with
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Voriconazole this treatment having a major impact on both clinical and radiological evolution –
regression of condensation and the disappearance of the other 2 opacities.
Discussion
Case 1: Apparent immunocompetent child with bronchopneumonia with difficult evolution

despite of broad-spectrum antibiotics. Persistent abnormalities from the chest x-rays raised
suspicion of pre-existent cyst on a possible bronchial malformation but the computed tomography
performed at 1-month distance invalidated this assumption.
Case 2: Older child, without medical history, that developed parapneumonic pleural effusion,
pulmonary abscess and empyema. In this case, the simple thoracic drainage was not efficient, and
the patient needed pleuropulmonary decortication. The minimally invasive procedure (VAT) is
recommended and was applied in this case with a good outcome, without the sequelae of a
thoracotomy.
Case 3: Immunosuppressed child, known with acute myeloid leukaemia (positive FLT3-ITD
mutation), with late medullary relapse that developed probably a fungal respiratory pneumonia
since she responded to antifungic drugs.
The evolution of the three cases was difficult, all children needing ICU care. Cultures collected
for all of them came out negative, probably secondary to the fact that they received antibiotic
treatment at home, before carrying out tests. Yet, after receiving broad spectrum antibiotics and
supportive treatment the evolution was favourable in the end.
Complicated pneumonia is an important paediatric problem. The choice of the antibiotic is made
based on few available data and suggested recommendations from guidelines. Even though the
diagnostic tests are advanced and the immunization coverage is increased as well as treatment
options that are available nowadays, the mortality remains high, particularly in developing
countries. (6, 9)
The antibiotic therapy is, probably the most important aspect of treatment in pneumonia but the
supportive care has a role to play in the recovery of the patients diagnosed with this pathology. Yet
there are various recommendations of international guidelines for antibiotic therapy in pneumonia
the optimal choice and duration of antibiotic treatment is still debated. (4, 10, 11)
Empirical antibiotic treatment is still valid in clinical management of pneumonia cases both in
children and adults. (9, 10)
The problem of antibiotic resistance among various pathogens in pneumonia is widely
recognized. (10) Over time a big number of drugs have been developed against drug-resistant
pathogens and some drugs are still developing. Reasonable use of antibiotics, starting with narrow
spectrum drugs and the shortest possible duration may help in reducing the drug resistance. (7, 9)
Complication such as empyema and lung access often need surgery procedures in addition to
antibiotic treatment such as video-assisted thoracoscopy or insertion of percutaneous small-bore
drainage with instillation of fibrinolytics. (9, 10, 11, 12, 13)
Repeated ultrasounds may be required in the monitoring these patients, in the case of clinical
deterioration as fluid may accumulate rapidly. (12, 14) The radiologic image may remain abnormal
for up to 6 months after treatment. Usually children fully recover without long term sequelae, but
complications are possible such as: fistulae (broncho-pleural or cutaneous), bacteremia,
endocarditis, persistent lobar collapse. (12, 13, 14, 15, 16)
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Conclusion
Despite progresses that were made in the last century concerning the antibiotic treatment in
pneumonia there are still cases that develop severe complications that require multidisciplinary
approach.
REFERENCES
1. Management of Complicated Pneumonia in Childhood: A Review of Recent Literature.

Darby JB1, Singh A1, Quinonez R1 – Rev Recent Clin Trials. 2017; 12(4): pp. 253-259. doi:
10.2174/1574887112666170816144110.
2. Etiology and Impact of Coinfections in Children Hospitalized with Community-Acquired Pneumonia Vikki
G. Nolan, Sandra R. Arnold, Anna M. Bramley, 6 et al., – The Journal of Infectious Diseases 2018; 218: pp.
179-88.
3. UNICEF. Child Health- Pneumonia. 2018 [cited 2018 June]. Available from:
https://data.unicef.org/topic/child-health/pneumonia/. Accessed 16 Nov 2018.
4. Complicated pneumonia in children. Rishi Pabary, Ian M. Balfour-Lynn – Breathe. 2013, volume 9, no. 3.
5. Pneumonia and diarrhea: Tackling the deadliest diseases for the world’s poorest children. New York,
UNICEF, 2012.
6. Levels and Tends in Child Mortality: Report 2011. UN Inter-agency Group for Child Mortality Estimation,
2011.
7. International survey of paediatric infectious diseases consultants on the management of community-acquired
pneumonia complicated by pleural empyema Joshua Osowicki and Andrew C Steer Journal of Paediatrics
and Child Health 55 (2019) pp. 66-73.
8. Infants and Children: Acute Management of Community Acquired Pneumonia Guideline 2018 NHS
Government, Health.
9. Mortality Predictive Scores for Community-Acquired Pneumonia in Children Antonio Arbo, Dolores Lovera,
Celia Martínez-Cuellar Current Infectious Disease Reports (2019) 21: 10 https://doi.org/10.1007/s11908-019-
0666-9
10. Antimicrobial Therapy in Community-Acquired Pneumonia in Children Samriti Gupta, Rakesh Lodha, SK
Kabra Current – Infectious Disease Reports (2018) 20: p. 47 https://doi.org/10.1007/s11908-018-0653-6
11. Trends in Pediatric Complicated Pneumonia in an Ontario Local Health Integration Network, Tahereh Haji,
Adam Byrne, and Tom Kovesi Children 2018, 5, 36; doi: 10.3390/children5030036
12. Video thoracoscopic surgery before and after chest tube drainage for children with complicated
parapneumonic effusion Rogerio Knebela, Jose Carlos Fragab,c, Sergio Luis Amantead, Paola Brolin Santis
Isolanb J Pediatr (Rio J). 2018; 94(2): pp. 140-145.
13. Risk Factors for Severe Community-acquired Pneumonia Among Children Hospitalized With CAP Younger
Than 5 Years of Age Shan, W, Shi, T, Chen, KL, PEDIATRIC INFECTIOUS DISEASE JOURNAL, Issue
3, volume 38, 224-229 DOI: 10.1097/INF.0000000000002098
14. Williams DJ, Zhu Y, Grijalva CG, et al., Predicting severe pneumonia outcomes in children. Pediatrics. 2016;
138: e20161019. https://doi.org/10.1542/peds.2016-1019.
15. Etiologic spectrum and occurrence of coinfections in children hospitalized with community-acquired
pneumonia. JiangW,Wu M, Zhou J, et al., BMC Infect Dis. 2017;17:787. https://doi.org/10. 1186/s12879-
017-2891-x.
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Figures
Fig. 1. Dilated bowel loops, two c on the left iliac fossa; absence of pneumoperitoneum
Fig. 2. Transparent lesion of 35/24mm, circled by a 3mm peripheric opaque ring located in the posterior side of
left-superior lobe; two air-fluid levels of 8mm and respectively, 40mm located at the posterior basis of left lung
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Fig. 3. Mild interstital infiltrate of both lungs; Fig. 4. Opacity on the upper right lobe
pulmonary two radiotransparent lesions that appear to and communicate onthe superior located
presence of fluid in the right costo-diafragmatic sinus near heart
Fig. 5. Right empyema with the thickness of fluid of 27 mm and 22mm thickness of air level
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Fig. 6. Air bubbles within the fluid collection of the right lung
Fig. 7. Pulmonary consolidation, inhomogeneous, with multiple aeric cysts with sizes from 11mm to 42.3mm
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Fig. 8. Non-homogeneous opacity in medium 2/3 of the Fig. 9. VAT for pleuropulmonary empyema
right hemithorax
Fig. 10. Same case as in Fig 4-9. after 1 month Fig. 11. Medium intensity opacity, inhomogenous
of treatment located at the base of right ung and 2 other opacities
located retrocardiac
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Fig. 12. Slow favourable evolution: regression of condensation and the disappearance of the other opacities
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The Onset of Dementia Through the Cotard Syndrome – The

Delirium of Negation
DARIE Cristina1, CIUBARA Anamaria2

1Resident psychiatrist, Hospital of Psychiatry “Elisabeta Doamna”, Galati, (ROMANIA)
2MD PhD, Hab. Professor at Faculty of Medicine and Pharmacy, University “Dunarea de Jos”, Head of Psychiatry Department,
Senior Psychiatrist (ROMANIA)
Emails: anamaria.ciubara@ugal.ro, cristina.darie27@yahoo.com
Abstract
Introduction
Cotard syndrome is a neuropsychiatric pathology rarely seen in medical practice, but with a
strong impact on the awareness of the importance of mental health. This mental disorder is also
known as negation delirium, living dead syndrome, nihilistic delirium, or walking corpse
syndrome.
Objectives
Presentation of a patient’s clinical case diagnosed with dementia in late-onset Alzheimer’s
disease; dementia also includes symptoms of Cotard’s syndrome. The transmission of knowledge
and data about Cotard Syndrome, which, despite its very low frequency, over time, is a pathology
that intrigues and inspires curiosity among individuals. In a number of psychiatric pathologies,
consciousness of the existence of this delirious illness and the accurate definition of the symptoms
of a dual diagnosis.
Method
In order to carry out this document, we used the Psychiatry Hospital Database “Elisabeta
Doamna” from Galati, Romania, where patient data was accessed and admitted to the Psychiatry
Clinic Section II, looking for various bibliographical references, diagnostic criteria ICD-10
(Classification of Mental and Behavioural Diseases), diagnostic criteria DSM-5 (Diagnostic and
Statistical Disorders) and the psychometric tests MMSE (Mini Mental Status Test) and GAFS
(Global Functioning Assessment Scale).
Results and Conclusions

Although the patient had no psychiatric history, she arrived at the Psychiatric Hospital following
psychiatric symptoms determined by both Alzheimer’s dementia and Cotard’s syndrome,
symptoms that were ignored and gradually deteriorated, leading to full delirium evolution, fast
dementia degradation, and no favourable outlook.
Keywords: Cotard Syndrome, Alzheimer disease, delirium of negation, dementia, psychiatry
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Introduction
Cotard Syndrome, a disease with a small incidence, determines individuals to doubt their own
presence, so that some individuals think that they are dead, consider that they lack body
components, distinct organs, or have NO body, and this last symptom is deemed, according to the
author’s classification, to be the most severe case of homonymous syndrome. This mental illness,
although discovered in 1788, was observed and analysed by a number of people, was officially
defined by the French neurologist, Jules Cotard, only in 1880, by a lecture provided by the Medical
Psychological Society in Paris. At that time, Cotard described this psychotic denial of his own
existence as a deep, melancholy dementia, often linked to severe hypochondria, depression,
suicidal tendencies, and the powerful conviction of the person that his life is over and that he is
already dead; in a few of these cases, patients believed themselves to be immortal people or gods.
In his article, Cotard also referred to the reports of other French physicians who had patients
suffering from this disease, who believed they had lost all their blood or had no brain, head,
stomach, heart or other organs, or were in a rotten state [1].
The delusional concept is a disruption of the function of thought, which produces an incorrect
reflection of reality, and the pathological character of these multiple diseases is not recognized by
the person involved, which leads to a adverse, pathological modification of the conception of
culture, the globe and, finally, the association of another psychiatric disease, the personality
disorder.
Cotard’s syndrome is mainly defined by the presence of an illusionary concept, a delirious idea
of negation. Paradoxically, the delirium of negation differs from the other types of delirious
thoughts by the following element: the patient himself defines the existence of delirium, implicitly
involving himself in the corresponding life, firmly believing in delirious concepts, while imposing
the presence of another individual for the diagnosis of other delirious syndromes [2]. Dementia, as
described in ICD-10 (Mental and Behavioural Disorders Classification), is a chronic or progressive
brain disease syndrome in which many higher cortical functions, including mental function,
thinking, orientation, comprehension, computation, learning ability, language, and judgment, are
deteriorated [3]. Degradations of cognitive function are generally followed by deterioration of
social behaviour, emotional control, or motivation. In view of the fact that dementia causes a
marked decrease in intellectual functioning, it can also be defined as a malfunction in day-to-day
operations such as personal hygiene, washing, clothing, feeding, etc [3]. Alzheimer’s disease is
currently considered irreversible, with unknown ethiology and neuropathological and
neurochemical characteristics as the main degenerative brain disease [3]. The onset of this disease
may occur in or even earlier in the center of adult life, but the incidence is higher in the latter part
of life [3]. In cases with onset prior to the age of 65 (dementia in early onset of Alzheimer’s
disease), there is a chance of a family history of comparable dementia with faster evolution and
more prominent characteristics, indicating temporal lobe and parietal lesion, including dysphagia
and dyspraxia [3].
In cases of late onset (dementia in late onset Alzheimer’s disease), the progression of the disease
may be slower and almost globally characterized by a deterioration of superior cortical functions
[3].
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Late-onset Alzheimer’s disease dementia and its association with Cotard’s disease
Presentation of clinical case
Mrs. M.A. Patient, female, Romanian, Christian-Orthodox, 69-year-old, urban, in emergency
and accompanied by parents, in the Psychiatric Hospital “Elisabeta Doamna”, Galati, Romania, on
13 November 2018, accused the psychiatric symptomatology described below.
Hospitalization Reasons
Delirious concept of death (I feel like I died)
Practical function difficulties (spontaneous and voluntary hypoprosis)
Mnestic function difficulties (fixing and evocation hypomnosis)
Behavioural disorder
Temporal-spatial (partial) disorientation
Anamnesis
History of hereditary collateral – not important

Personal physiological history, first menstruation – 14 years, menopause – 50 years, 7
pregnancies, 3 natural births, 4 spontaneous abortions
Personal Pathological history: HTA (hypertension) over 15 years, she is in therapy but in latest
months, background medicine has been overlooked.
Personal surgical pathology history

Tonsillectomy at 15 years, Appendectomy at 18 years.
Psychiatric pathological background
The patient was not registered and was never admitted to a psychiatric hospital.
Living and working circumstances
The patient lives with her husband in the urban area, she graduated in eight courses, worked in the
bakery sector for 20 years, is currently a retired person, spends most of her time at home; in the
last few years, she has been taking care of her husband because of various somatic circumstances,
with friends or neighbours who are no longer socializing as before, three children rarely visit her
(1-2 times a month), 2 pets (cats).
Behaviours: For 30 years the patient has been smoking 10 cigarettes per day
Background medication
Indapamindum tablets, 1.5 mg 1cp/day; Metoprolol, tablets, 50 mg, 2 cp/day Intermittent
background therapy for which the person often had hypertensive outbreaks was administered.
History of Disease
The originators report many years ago on the start of dementia phenomenology. Initially, family
members observed the symptoms because of difficulties in remembering recent events (the patient
couldn’t remember what she ate when she was shopping or when she closed the door when she left
home). Members of her family noticed the onset of dementia phenomenology many years ago.
Initially, the symptoms were noted by family members due to problems in remembering latest
incidents (the patient could not remember what she ate when she was shopping or when she closed
the door when she left home). Symptoms gradually worsened by exacerbating mental illnesses that
restricted their degree of social functioning (issues in fulfilling their day-to-day responsibilities –
cooking, washing, cleaning, shopping). Suddenly, three weeks ago, the patient began reporting
225
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theft thoughts (she could no longer find things and thus accused her parents of stealing things),
then the ideas took on strange forms (elements of Cotard Syndrome, which is why the patient was
taken to the Psychiatric Hospital by ambulance).
Psychological Examination
Facies and hypermobic imitations, expressing internal tension, state of anxiety; the patient wears
a seasonal and age-related city costume, but is disturbed, maintaining body hygiene with the
assistance of the caregivers; the psycho-verbal contact is relatively easy to establish, with the
pressure to talk, the visual contact is attempted and maintained, expressing internal anxiety,
spontaneous speech, started without problems, high pitch, high flow, precipitated on an anxious
background, decreased lexicon, suspicious, hostile attitude, against delirious ideation, hyperkinesia
with nocturnal amplification.
The patient is lucid, temporary disorientation (he doesn’t understand the year, the day, but he
knows the month and the season) of spatial disorientation (he knows the country, the county, the
city, he doesn’t know the hospital) of self-orientation and psychological difficulty.
The patient has physical hypoesthesia, rejects qualitative perception disturbances, physical
hypnosis, spontaneous and voluntary hypoprosis, fixation and evocation hypnosis, contextually
accelerated rhythm and ideo-verbal flow, poor vocabulary, poor school readiness (poor patient and
school preparation) sentences to describe what she feels. With the alteration of social behaviour
and accentuation during the night, against the background of cognitive disorientation, the content
of the idea is dominated by the illusion of the Cotard type (I feel like I’m dead).
The idea has grown quite sharply, causing an aggressive behavioural reaction. Anxious,
suspicious, misleading, misleading background.
Useful effectiveness decreased markedly, both by limiting the fundamental functioning (cooked,
dressed, consumed) in the context of dementia and by delirious backgrounds with a marked
deduction of instincts.
Impoverished global imagination, but alive in the context of the delusional idea. Intellect greatly
diminished from school preparation (due to cognitive disorder).
Low eating instincts (both in cognitive contexts, especially in delirious contexts, lack of defense
instinct in delirious cases, lack of sexual instinct due to age.
Hypnotic initiation, maintenance and awakening disorders, lack of insight (the patient does not
believe she has a mental illness) because she is confident, she has died; the patient also does not
recognize the prescribed therapy) [4].
Positive Diagnosis
Axis 1. Dementia in late-onset Alzheimer’s Disease

Axis 2. There are no elements
Axis 3. High blood pressure
Axis 4. Psychosocial factors-positive factors (married, has 3 children) and adverse variables
(children rarely visit her, family support is small, her spouse has different somatic circumstances
and does not assist her in daily duties or moral support, family relations are not favourable, as the
patient has gradually become socially isolated in recent years, both in comparison to families.
Axis 5. GAFS (Global Assessment of Functionality Scale) 30-50 points (severe
symptomatology: social isolation, abandonment of social and domestic activity, etc.) [5].
226
©
Late-onset Alzheimer’s disease, based on ICD-10 criteria: the onset of the disease is insidious
and progressive, with moderately severe intensity over several years.
Elements of the Cotard Syndrome: denial of one’s existence; the patient was strongly convinced
that he died, a profound dementia of melancholy.
Differential Screenings
1. Major neurocognitive diseases caused by other neurodegenerative mechanisms (Lewy body
disease, frontal-temporal degeneration) have an insidious onset and a gradual decrease in common
with Alzheimer’s disease, but have their own characteristics [6].
2. Cognitive disorders caused by medical conditions (neurological or systemic) hypothyroidism,
severe head trauma, vitamin B12 deficiency, anaemia) other simultaneous neurological or systemic
diseases should be considered neurological or systemic if the clinical picture can be justified by
temporal association and severity [6].
3. Major depressive disorder, particularly in the case of mild neurocognitive disorders,
differential diagnosis should include major depressive disorder [6, 7, 8].
4. Acute psychotic disorder due to a medical condition
5. Delusional disorder
6. Simulation
7. Cognitive disorders due to substance use [6].
Case Management
1. Drug treatment Acute – therapy to reduce hyperkinesia and delirious ideation Antipsychotic
therapy has been initiated for delirious ideation, high-dose antidepressant therapy and sedative
therapy for hypnotic diseases.
2. Clinical psychological evaluation
It was performed with MMSE and GAFS, leading to moderately severe dementia, but with a
tiny functional GAFS of 30-50 points.
During treatment, the patient stabilizes with reduced behavioural syndrome, but with the
persistence of the ideation of the Cotard type, the intensity of which has decreased at a prevalent
and obsessive level, the patient does not have hyperkinesia. Drug therapy and psychological advice
are given to the patient [2].
Evolution and Prognosis
Due to more significant factors-old age, lack of family support, discontinuation of

antihypertensive therapy, and diagnosis of dementia, or chronic progressive disease-prognosis is
reserved. The patient was sent to the higher-ranking Psychiatric Hospital in Bucharest, where the
diagnosis of Late Onset Dementia and Cotard Syndrome remained. The control is introduced by
the patient for the continuation of the therapy. After the debate with the parents, the specialized
control showed a persistence of Cotard Syndrome, but a decrease in intensity (obsessive) and a
continuous evolution of the frequency of dementia (MMS, stationary GAFS) [2].
Particularity of the Case
This is a special situation, the diagnosis is first discovered in the psychiatric hospital in Galati,
and the link between late-onset Alzheimer's dementia and Cotard’s syndrome is unique because
Negation’s syndrome generally happens in schizophrenia, bipolar affective disorder, severe
227
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anxiety, not dementia. Another particular feature of the scenario is that Cotard Syndrome is an
early sign of Alzheimer.
Results and Conclusions
Approximately 300 medical cases have been researched and analysed in specialized literature
in which the diagnosis of Cotard syndrome has been linked to psychiatric, neurological or traumatic
pathologies. The statistical analysis showed an increased incidence between the ages of 50 and 60
in young adults, but also in elderly individuals, especially in female sex. Such cases are difficult to
treat because patients no longer feed themselves, their appetite for food is suppressed, they
constantly refuse food, arguing that they do not have the digestive system or parts of it anyway, so
they do not need food, so this behaviour has serious consequences for the body and even leads to
the death of the sick due to starvation [4]. British neuropsychologist Paul Broks suggests this
syndrome of negation may be based on a neurological disorder leading to a decoupling of feelings
of thought. So, thinking that we exist is not enough, but feeling it. Broks therefore claims that the
saying of Descartes, “I believe so I exist” (cogito, ergo sum) must be altered to I feel like I believe
so I exist. Cotard’s syndrome is part of a group of rare, strange mental illnesses that have too little
data or information and are difficult to diagnose and treat.
Examples of Cotard’s delusion case reports
1. Mademoiselle X, as Cotard called her in his notes, claimed to have “no brain, no nerves, no
chest, no stomach and no intestines.” Despite this predicament, she also believed that she “was
eternal and would live for ever.” Since she was immortal, and didn’t have any innards anyway, she
didn’t see a need to eat, and soon died of starvation.
2. In 2008, New York psychiatrists reported on a 53-year-old patient, Ms. Lee, who complained
that she was dead and smelled like rotting flesh. She asked her family to take her to a morgue so
that she could be with other dead people. They dialled 911 instead. Ms. Lee was admitted to the
psychiatric unit, where she accused paramedics of trying to burn her house down. After a month or
so of a drug regimen, she was released with great improvement in her symptoms.
3. In 1996, a Scottish man who suffered head injury in a motorcycling accident began to believe
he had died from complications during his recovery. Not long after he completed recovery, he and
his mother moved from Edinburgh to South Africa. The heat, he explained to his doctors, confirmed
his belief because only Hell could be so hot.
4. In 2012, Japanese doctors described a 69-year-old patient who declared to one of the doctors,
“I guess I am dead. I’d like to ask for your opinion.” When the doctor asked him whether a dead
man could speak, the patient recognized that his condition defied logic, but could not shake his
conviction that he was deceased. After a year, his delusion passed, but he insisted on the truth of
what happened during it. “Now I am alive. But I was once dead at that time,” he said.
5. In 2009, Belgian psychiatrists reported the case of an 88-year-old man who came to their
hospital with symptoms of depression. The man explained that he was dead, and was concerned
and anxious that no one had buried him yet. His delusions subsided with treatment.
6. The same doctors also treated a 46-year-old woman who claimed to have not eaten nor gone
to the bathroom in months, nor slept in years. She explained that all her organs had rotted, that she
had no blood and that doctors who monitored her heart or took her blood pressure were deceiving
her because her heart didn’t beat. After multiple admissions to the hospital and a lapse in taking
her medication over the next 10 months, her condition gradually improved.
228
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7. Greek psychiatrists received a patient in 2003 who believed he was literally empty-headed.
He had attempted suicide years earlier because he thought it wasn’t worth living since, he didn’t
have a brain. He was not treated after the incident and simply returned to work. Once at the hospital
he “claimed that he was born ‘without a mind,’ meaning that his head is empty without a brain and
for this reason he is retarded.” He left against medical advice after several days, and was re-
admitted the next year. This time he completed treatment and showed sustained improvement in a
follow-up interview months later.
8. The Greek doctors also treated a 72-year-old woman who went to the ER claiming “all of her
organs had melted; only skin had remained and that she was practically dead.” She was admitted
to the hospital and her outcome not reported.
9. In 2005, Iranian doctors described what may be the most unusual case recorded. A 32-year-
old man arrived at their hospital saying that not only was he dead, but that he had been turned into
a dog. He said that his wife had suffered the same fate. His three daughters, he believed, had also
died and had turned into sheep. He said that his relatives had tried to poison him, but that nothing
could hurt him because God protected him even in death. He was diagnosed with Cotard’s and
clinical lycanthropy, treated with electro-convulsive therapy and relieved of his major symptoms.
REFERENCES
1. Lidia Nica-Udangiu, Dan Prelipceanu, Radu Mihailescu, Ed. SCRIPTA, 2000, Emergency Guide in
Psychiatry, pp. 42-62, pp. 152-155.
2. Harold I. Kaplan, Benjamin J. Sadock, Virginia A. Sadock, Clinical Psychiatry, Ed. 11, 2015, Synopsis of
Psychiatry, pp. 185-205.
3. World Health Organization (WHO), (1992, 1993) ICD-10 International statistical classification of diseases
and related health problems. Classification of mental and behavioural disorders, pp. 47-50.
4. Dan Prelipceanu, 2011, Ed. EM, Clinical Psychiatry, pp. 60-62, pp. 830-837.
5. Harold I. Kaplan, Benjamin J. Sadock, Virginia A. Sadock, 2001, Pocket Handbook of Clinical Psychiatry,
2001, Ed. III.
6. American Psychiatric Association, 5th edition, 2013, DSM-5, Diagnostic and statistical manual of mental
disorders, pp. 590-618.
12-20.
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Filodiritto Editore – Proceedings

(Galatia, 8-12 May 2019)

Log in to find out all the titles of our catalogue

First Edition November 2019

© Copyright 2019 Filodiritto Publisher

Anxiety – Therapeutic Options from Past to Present 10

Sexual Functioning in Schizophrenic and Bipolar Female Patients 16

The Importance of the Supportive Psychotherapy for the Cancer Patients

Self-perception and Eating Behaviour in Obesity and Diabetes 28

From Depression to Human Immunodeficiency Virus – A Case Report 34

Psychiatric Disorders Associated with Endocrine Dysfunctions 39

Sexual Dysfunctions in Schizophrenia – A General Overview of

Eating Disorders Associated with Mood [Affective] Disorders 56

Dreaming and Parasomnias from a Cerebral Structural View 69

The Identity of the Psychiatric Patient – Between the Narrative Self

Falsification and Counterfeiting of Pharmaceutical Products. Poisoned Elixir –

Dual Diagnosis. Alcohol Consumption Associated with

Pharmacological Add-On Treatments in Managing Antipsychotic-Induced

Mindfulness: A Psychotherapeutic Method of Acceptance and Centering

Psiho-Oncologia. Case Presentation 108

Burnout Risk Evaluation in Medical Oncology – Radiotherapy Personnel 128

The Prevention of Dementia Before and After Stroke 135

Factitious Disorders – Challenges in Psychiatric Diagnosis 140

Trends in the Treatment of Patients with Disorder Linked with Alcohol

Peculiarities of Depressive Disorder in Elderly Patients 152

Comparative Assessment of Community-Based Mental Health Services (CBMH)

Complications of Hips Hemiarthroplasty at Pacient with Dementia 169

Work-related Temporomandibular Joint Disorders and Cognitive Behavioural

The Value of Cognitive Therapy in the Treatment of Dental Phobia 180

Ketamine in Perioperative Depressive Symptoms (PDS) Improvement –

Social Media Addiction in Adolescents and Young Adults –

The Role of Polyunsaturated Fatty Acids in Neurocognitive Development

Supraclavicular and Cervical Lymph Node Metastases Having Cervical Cancer

Polyradiculoneuritis in an Adolescent after Acute Pneumony 208

Difficulties in the Therapeutic Management of Complicated Pneumonia

The Onset of Dementia Through the Cotard Syndrome – The Delirium

THE EDITORIAL BOARD FOR THIS ISSUE

Anxiety – Therapeutic Options from Past to Present

MANEA Mirela1, CIOBANU Adela Magdalena2, MANEA Mihnea Costin3

Davila” University of Medicine and Pharmacy Bucharest (ROMANIA)

of Medicine and Pharmacy Bucharest (ROMANIA)

Management of Anxious Disorders

1. Predescu, V., (sub redactia), Psihiatrie, Ed Medicala 1976, p. 179.

Sexual Functioning in Schizophrenic and Bipolar Female Patients

MICLUŢIA Ioana Valentina1, DAMIAN Laura2, ŞERBAN Ana Cristina3

Material and Methods

Material and Methods

Table 1. Demographic data of the samples

As with regard of the frequency of sexual intercourse, schizophrenic females reported in

Fig. 1. Patterns of sexual disorders in depression/mania (14)

The Importance of the Supportive Psychotherapy for the Cancer

Psychotherapy is an interdisciplinary field, located at the border between medicine and

Communication of the Diagnosis

The Psychological Stages of the Cancer Patient

Comparative Study on the Effects of Supportive Psychotherapy on Patients Diagnosed with

psychological counselling or psychotherapy. The results of supportive psychotherapy have greatly

Group A. Self-esteem, graphic representation

Group B. Self-esteem, graphic representation

Group A. Self-acceptance scale, graphic representation

Group B. Self-acceptance scale, graphic representation

The Effects of the Supportive Therapy

The main benefits of participating in the oncology-supportive psychotherapy or support groups