Documente Academic
Documente Profesional
Documente Cultură
Redactor ef:
Dan PRELIPCEANU
Redactor-efi
adjunci:
Drago MARINESCU
Aurel NIRETEAN
COLECTIV REDACIONAL
Doina COZMAN
Liana DEHELEAN
Marieta GABO GRECU
Maria LADEA
Cristinel TEFNESCU
Ctlina TUDOSE
Secretari de redacie: Elena CLINESCU
Valentin MATEI
CONSILIU TIINIFIC
Vasile CHIRI (membru de onoare
al Academiei de tiine Medicale,
Iai)
Michael DAVIDSON (Professor, Sackler
School of Medicine Tel Aviv Univ.,
Mount Sinai School of Medicine,
New York)
Virgil ENTESCU (membru al Academiei de
tiine Medicale, Satu Mare)
Ioana MICLUIA (UMF Cluj-Napoca)
erban IONESCU (Universitatea
Paris VIII, Universitatea TroisRivieres, Quebec)
Mircea LZRESCU (membru de onoare al
Academiei de tiine Medicale,
Timisoara)
Juan E. MEZZICH (Professor of Psychiatry
and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
Sinai School of Medicine, New York
University)
Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Department of Psychiatry,
University of Maryland School of
Medicine, Baltimore)
Sorin RIGA (cercettor principal gr.I)
Dan RUJESCU (Head of Psychiatric
Genomics and Neurobiology
and of Division of Molecular and
Clinical Neurobiology, Department
of Psychiatry, Ludwig- MaximiliansUniversity, Munchen)
Eliot SOREL (George Washington
University, Washington DC)
Maria GRIGOROIU-ERBNESCU
(cercettor principal gr.I)
Tudor UDRITOIU (UMF Craiova)
ARPP
REVISTA
ROMN
de
PSIHIATRIE
ASOCIAIA ROMN
DE PSIHIATRIE I PSIHOTERAPIE
Vol XVII
www.romjpsychiat.ro
CNCSIS B+
Nr. 3
September 2015
QUARTERLY
p-ISSN: 1454-7848
e-ISSN: 2068-7176
CUPRINS
ARTICOLE SPECIALE
& Actualiti diagnostice n tulburrile de personalitate
41
Aurel Niretean, Lukacs Emese, Tudor Niretean, Istvan Zsolt Szasz, Adrian Horvath, Adina Mari
44
Ileana S. Constantin
ARTICOLE DE SINTEZ
& Simptomele negative n schizofrenie: de la Kraepelin la DSM 5
48
51
Eva K Lakatos, Elena Minciu, Lrnd J Lakatos, Anna Keszegpal, Aurel Niretean, Adina Mari
56
ARTICOLE ORIGINALE
& Tulburri de somatizare la copii i adolesceni - o perspectiv local din judeul Galai
63
77
CAZ CLINIC
& Provocri diagnostice la o pacient cu tulburare psihotic dup transplant hepatic
84
Revista Romn de Psihiatrie este indexat de Consiliul Naional al Cercetrii tiinifice din
nvmntul Superior la categoria B+. Apare trimestrial.
Colegiul Medicilor din Romnia acord abonailor la aceast publicaie 5 credite EMC/an.
Articolele tiinifice publicate n revist sunt creditate cu 80 credite EMC/articol.
Revista Romn de Psihiatrie este editat de Asociaia Romn de Psihiatrie i Psihoterapie
i Asociaia Medical Romn
88
SPECIAL ARTICLES
Rezumat:
Tulburarile personalitatii se reconfirma mereu ca un
domeniu al controverselor. Astazi,complicatiile
psihatrice si sociale ale comportamentului
pacientilor cu tulburari de personalitate sunt de o
diversitate si gravitate particulara. Ele pot fi
favorizate,mascate sau modelate de mediul sociocultural. De aceea precocitatea si acuratetea
diagnosticului devin deosebit de importante. Acesta
trebuie sa fie un proces elaborat, fundamentat clinic
si psihometric dar conditionat cultural si moral.
Cuvinte cheie: tulburarile de personalitate,
diagnostic, factori socio-culturali
41
Aurel Niretean, Lukacs Emese, Tudor Niretean, Istvan Zsolt Szasz, Adrian Horvath, Adina Mari: Personality
Disorders Diagnostic Actualities
Self-image and self-esteem become
thereby fragile and inauthentic, contradictory or they are
in a paradox relationship. All pathological personalities
seek through the mentioned methods access to a
version of selfish happiness, solitary and lacking depth
and authenticity.
For the reasons thus outlined the diagnosis
of the personality disorders becomes a complex process of
which accuracy depends of a multitude of variables.
Among these, the ego-syntonic character of psychobehavioral manifestations and the congruence between
maladaptive traits and biographical experiences which
condition and favour each other, have a prevailing role. In
the same context, the diagnostic approach is influenced by
demographic factors, the mentality and preconceptions of
the entourage, by the frequent association with episodes
and disease of Axis I, as well as by the relativity of rules,
conduct patterns and contemporary community values.
Any diagnostic approach in the given
context means simultaneously also a moral approach
appropriate to its stigmatizing character favoured by the
ignorance of the medical sphere and profane world, by
negative semantic conditioning, by self-perception and
poor self-control of the maladaptive traits, by the negative
impact of biographical narrative descriptions and of
course by the always unpleasant consequences of the
disharmonic behaviour on the entourage.
Currently, in diagnosing personality
disorders, important are the maladaptive manifestations
and their effects on the entourage, next to the development
of the intentionality of personal attitudes and acts. These
are to the disadvantage of the current condition and the
biographic moment lived. Starting from the premise that
patients' narrations have an egocentric, unstable and
manipulative character, the diagnosis has a particular
complexity integrating clinical interviews and structured
ones, a great variety of scales and questionnaires that aim
towards among other various references both
biographic memory and subjective well-being.
Heteroanamnesis and autobiographical narration contents
have a particular role.
Personality Disorders represent a distinct
nosologic category that imprint in a specific manner on
everyday behaviour, being at the same time quantitative
versions of certain essential and general dimensions of the
normal personality. This is why the categorical
personologic diagnosis must always be followed by a
complementary dimensional approach. This double
perspective confers to it a dynamic and staged character in
which there are integrated demographic, social and
economic, cultural, spiritual and moral references. The
diagnosis approach thus structured pleads for the fact that
the personality dimensions may modify in time and in
relation to factors of environment and confer also by this
means complexity and accuracy to the therapeutic and
rehabilitative interventions.
Nowadays, from the categorical
perspective are kept the three clusters - A, B and C,
corresponding to bizarre, eccentric and dissocial
personalities, respectively to the anxious ones to which
are added the personopathies due to a medical condition
and that is temporary epilepsy, in which the intercritical
behaviour is dominated by affective lability, by
impulsivity, by aggressiveness, by paranoidism and
42
***
43
SPECIAL ARTICLES
Rezumat :
1
M.D.Psychiatry. Personal address: Bd. Constructorilor 24, Bl.19, Sc A, Ap 28, Sector 6, Bucuresti.
Contact: ileana_cons@yahoo.com, phone no. 0723574524
44
Factor
S=Sex (male)
A=Age (<19 or >45 years)
D=Depression
P=Previous suicide attempts
E=Ethanol abuse
R=Rational thinking loss
S=Social support lacking
O=Organized plan
N=No spouse
S=Sickness (chronic, debilitating disease)
Points
1
1
1
1
1
1
1
1
1
1
Level 1-3
None
Level 4-6
Few
Suicidal
communication
Occasionally absent /
present in tense situations or
under the influence of
alcohol
Previous suicide
attempts
None
Previous, well-planned
attempts
Overall picture
of suicidal
process
Self-aggressive behavior,
previous attempts to commit
suicide by intoxication
Problems,
resources and
relationships
Somatic disorder
None
Mild pathology
Psychiatric
disorder
None
Depression, obsessive
compulsive disorder,
impulsiveness
None
Suicide Ladder
Risk factors
Conscious
predisposition to
suicide
Abuse/addiction
46
High risk
Level 7-9
Many
Structured suicidal plans,
active suicide method in the
near future
***
47
REVIEW ARTICLES
Rezumat:
Diagnosticul de schizofrenie cuprinde simptome pozitive,
negative, cognitive, afective si deorganizare. Simptomele
negative reflect absena sau deficitul funcionrii
emoionale i profesionale, iar simptomele pozitive
reprezint o exagerare a experienelor normale. Lucrarea
de fa descrie conceptul de simptome negative de la
originile sale pn la perspectiva adoptat n DSM V.
Noiunea de simptome negative i-a rectigat importana
datorit asocierii acestor simptome cu o capacitate
sczut de funcionare global i datorit faptului c
tratamentele actuale controleaz simptomele pozitive, la
cei mai muli pacieni, dar au o eficacitate diminuat
asupra simptomelor negative.
Cuvinte cheie: perspectiv istoric, diminuarea
expresivitii, avoliie/apatie.
INTRODUCTION
Schizophrenia is a chronic, debilitating disorder
of the young adult, with a multifactorial etiology,
characterized by significant dysfunctions in cognition,
thought process, perception, affect and social functioning.
The diagnosis of schizophrenia is based on
positive, negative, cognitive, disorganized and affective
symptoms. The dichotomy between negative and positive
symptoms reflects for the negative symptoms the absence
or the lack of emotional and behavioral functioning and for
the positive symptoms add-ons to normal experiences.(1)
These terms were first used by the neurologist Sir John
Reynolds to describe the loss or the excess of vital
properties which he observed in patients with epilepsy.
(2)
The negative symptoms of schizophrenia
encompass blunted affect, alogia, apathy, abulia, social
withdrawal, anhedonia. The positive symptoms, which
were known in the classical literature as productive
symptoms, comprise hallucinations and delusions. (3)
EARLY DESCRIPTIONS OF NEGATIVE SYMPTOMS
The description of negative symptoms goes back
over a century to Kraepelin's dementia praecox concept.
Kraepelin considered the affect deficit as a core symptom
of the disease and to be underpinning the motivational
deficits: the lack of interest, the indifference, the lack of
pleasure. He sustained this model based on the assumption
that all mental processes include an affective component.
Kraepelin named the disease dementia praecox because he
ascribed the emotional deficit to a degenerative process.
(1, 4)
Kurt Schneider in 1959 used a different system of
1
Assistant Professor, PhD student in Psychiatry, Department of Neuroscience, Iuliu Haieganu University of Medicine and Pharmacy, No. 8 Victor Babe
Street, 400012, Cluj-Napoca, Romania. Email: octavia.capatina@umfcluj.ro
2
Professor of Psychiatry, Head of Psychiatry Department, MD, PhD, Department of Neuroscience, Iuliu Haieganu University of Medicine and
Pharmacy, No. 8 Victor Babe Street, 400012, Cluj-Napoca, Romania. Email: ioanamiclu@yahoo.com
48
49
50
18. Nayaka M, Ohmori K. A two factor structure for the deficit syndrome
in schizophrenia. Psyciatry Res. 2008; 158: 256-259.
19. Strauss GP, Horan WP, Kirkpatrick B et al. Deconstructing negative
symptoms of schizophrenia: avolition-apathy and diminished expression
clusters predict clinical presentation and functional outcome. J Psychiatr
Res. 2013; 47(6):783-90.
20. Rocca P, Montemagni C, Zappia S et al. Negative symptoms and
everyday functioning in schizophrenia: A cross-sectional study in real
world-setting. Psychiatry Res. 2014; 218:284-289.
21. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders Fifth Edition. Arlington, VA: American
Psychiatric Publishing, 2013, 87-123.
22. Sicras-Mainar A, Maurino J, Ruiz-Beato E et al. Impact of negative
symptoms on healthcare resource utilization and associated costs in adult
outpatients with schizophrenia: a population-based study. BMC
Psychiatry 2014; 6:214:225.
23. Bobes J, Arango C, Garcia-Garcia M et al. CLAMORS Study
Collaborative Group: prevalence of negative symptoms in outpatients
with schizophrenia spectrum disorders treated with antipsychotics in
routine clinical practice: findings from the CLAMORS study. J Clin
Psychiatry 2010; 71:280-286.
24. Rabinowitz J, Levine SZ, Garibaldi G et al. Negative symptoms have
greater impact on functioning than positive symptoms in schizophrenia:
analysis of CATIE data. Schizophr Res. 2012; 137(1-3):147-50.
25. Fervaha G, Foussias G, Agid O et al. Impact of primary negative
symptoms on functional outcomes in schizophrenia. Eur Psychiatry
2014; 29(7):449-55.
26. Zaprutko T, Kus K, Bilobryvka R, et al. Schizophrenia and
Employment: Evaluation From Professionals Point of View. Psychiatr
Q. 2015. [Epub ahead of print]
27. Harvey PD. Assessment of everyday functioning in schizophrenia:
implications for treatments aimed at negative symptoms. Schizophr Res.
2013; 150(2-3):353-5.
***
REVIEW ARTICLES
Rezumat:
Etiologia i patogeneza bolilor cardiovasculare (BCV)
include att factori somatici ct i factori psihosociali i
comportamentali. n condiiile ritmurilor i
particularitilor social-economice din societatea
contemporan de hiperconsum, evaluarea contribuiei
factorilor personologici n determinismul i dinamica
BCV devine un deziderat de prim importan medical i
social. n ultimii 20-25 ani cercetrile au nceput s-i
recanalizeze interesul pe rolul personalitii n
prognosticul pacienilor cu BCV. Un nou tip de
personalitate, personalitatea de tip D sau distresseda
fost introdus, ca un factor de vulnerabilitate caracteristic
pacienilor cu boal cardiac. Aceasta se ntlnete
frecvent, prevalena n populaia general fiind ntre 1325% iar n rndul pacienilor cu BCV fiind chiar mai
ridicat. Se refer la un tip de personalitate, care
desemneaz indivizi nclinai spre a experimenta
dificulti emoionale i n relaiile interpersonale, care
pot afecta starea de sntate i combin ca trsturi
afectivitatea negativ (AN) i inhibiia social (IS).
Fuziunea acestor dou trsturi n personalitatea de tip D
prezice n mod credibil prognosticul negativ la mai multe
grupuri de pacieni cu BCV, independent de factorii de
risc biomedicali convenionali. Cercettorii i clinicienii
ar trebui s ia n considerare n practica clinic
predispoziia pacientului la distress-ul psihologic, care
poate fi uor de evaluat cu DS14, n vederea de a
mbunti starea de sntate mintal i fizic i de a
influena pozitiv progresia BCV la acest grup de pacieni
cu risc crescut.
Cuvinte cheie: afectivitate negativ, inhibiie social,
personalitate de tip D, boal cardiovascular, boal
coronarian ischemic
P E R S O N A L I T Y A N D C A R D I O VA S C U L A R
DISEASES (CVD)
The etiologies and pathogenesis of CVD as
hypertension, coronary artery disease (CAD) and heart
failure are complex. These include both biological factors
such as increased blood pressure, increased inflammation
and increased cardiac sympathetic tone (1, 2), and a wide
variety of psychosocial and behavioral factors as
depression (3, 4), chronic stress (5), anxiety (5, 6),
PhD student, University of Medicine and Pharmacy Targu-Mures, Str. Gh. Marinescu, Nr. 38, Jud. Mures, 540139, Romania.
MD, resident physician Cardiology, I. Cardiology Clinic for Adults, Emergency Institute of Cardiovascular Diseases and Transplantation Targu-Mures,
Str. Gh. Marinescu, nr. 50, Jud. Mures, 540136, Romania.
3
MD, Urology Specialist, Urology Department, Top-Med Medical Center, Str. Dorobantilor, Nr. 1-3, Targu Mures, Jud. Mures, 540103, Romania.
4
MD, resident physician Dermatovenerology, Department of Dermatovenerology, Emergency County Hospital Oradea, Str. Republicii, Nr. 37, Jud. Bihor,
410167, Romania.
5
MD, PhD, Professor, Chief of Psychiatry Department, University of Medicine and Pharmacy Targu-Mures, Romania, Str. Gh. Marinescu, Nr. 38, Jud.
Mure, 540139, Romania.
6
Senior psychologist,Pediatric Clinic No,1 ,UMF.Tg.Mures
2
51
Eva K Lakatos, Elena Minciu, Lrnd J Lakatos, Anna Keszegpal, Aurel Niretean, Adina Mari: Type D Personality In
Patients With Cardiovascular Diseases
cognitive, emotional, volitional-instinctual, motivational
and relational features, called dimensions. These
dimensions are general human features present, in varying
degrees, in all individuals with normal personality, in the
disharmonic structures of personality and are markers of
vulnerability for both psychiatric and somatic diseases.
All the population, normal and pathological people as
well, have the same dimensional universe, the same
substrate structure. Abnormal, maladaptive features of
personality, even those considered as diagnostic criteria
for some specific personality disorders can be met in
normal individuals (14). Recognizing these maladaptive
personality features is important from the perspective of
somatic diseases, especially CVD, because they
determine lifestyle, behavior such as low adherence to
treatment, neglect of physical activity, unhealthy diet and
smoking.
Non-psychopathological behavioral
characteristics were associated for the first time with
somatic diseases in the 1950s when M. Friedman and
Rosenman discovered (1959) a cluster of symptoms and
behavioral signs that predispose to risk of heart disease,
defined as type A behavior pattern. This pattern is one of
the competitive types with a tendency to interact with
others in an aggressive or hostile manner (12). It includes
ambitiousness, aggressiveness, competitiveness,
impatience, muscle tenseness, alertness, rapid and
empathic vocal style, irritation, cynicism, hostility and
increased potential for anger.Hostility was considered one
of the core features (15, 16, 17).
Psychological reverse of type A is the type B behavior
pattern that describes tolerant, tempered individuals,
which are not at increased risk for heart disease.
During the 1970s and 1980s several clinical trials
have evaluated the role of type A as a predictor of adverse
CV events related to CAD, establishing a small
relationship between angiographically determined CAD
and type A behavior pattern among younger patients (18).
Subsequently, due to these relatively unsatisfactory
results related to the type A behavior pattern, personality
factors have been mostly neglected in CV research since
(19, 20). Depression and to a lesser extent anxiety entered
into the spotlight. Although depression and depressive
symptoms are strong predictors of onset and progression
of heart disease (21, 22), the attempts to successfully
reduce biomedical risk factors (RF) by treating depression
have yielded mixed findings (23, 24).
In the last 20-25 years, researches have begun to
regain the interest on the role of personality in health and
disease (25, 26). This renewed attention is justified by the
fact that personality features may have greater
explanatory power than depression (5, 27, 28). There is
growing evidence that underline that dimensions such as
neuroticism are the base of psychiatric diagnoses such as
major depression (29, 30). Personality can have a
significant predictive value regarding the prognosis of
patients with CVD. Because of the known clustering of
unfavorable psychosocial characteristics (5), it is
important that a personality approach is taken in
identifying those patients who are at increased risk for
emotional stress-related cardiac events.
In 1995 a new personality type was introduced as a
vulnerability characteristic of patients with heart disease:
52
Eva K Lakatos, Elena Minciu, Lrnd J Lakatos, Anna Keszegpal, Aurel Niretean, Adina Mari: Type D Personality In
Patients With Cardiovascular Diseases
personality may be more likely to be more aware of
normal bodily sensations and to interpret them as painful
or pathological (42), and also, they tend to believe that
their illness will have more serious consequences and that
treatment will be less effective (64). This health condition
reported by patients has been shown to have a significant
predictive value over indicators of disease severity in
predicting mortality and rehospitalization (63).
Type D personality is associated with an unhealthy
lifestyle (e.g. smoking, alcohol consumption, physical
inactivity) (65), medication non-adherence (66) and
inadequate consultation behavior(67, 68).
CONCLUSIONS
Type D personality was associated with increased
morbidity and mortality in different CV populations
independently of conventional biomedical RF (69, 70)
and with an increased prevalence of CV RF (71).
Individuals with this type of personality have an increased
risk of developing psychiatric and medical disorders (31,
32).
When one considers the rhythm and the socioeconomic particularities of our contemporary society of
hyper-consumption, evaluating the contributions of
personality factors, in the determinism and dynamics of
CVD, becomes a paramount medical and social goal.
Studies have shown that type D personality is an important
and easily assessable negative prognostic predictor that
should be considered in clinical practice. It can be
regarded as a psychopathological condition that can affect
health and longevity and may require psychosocial and /
or pharmacologicalinterventions (72).
Further studies are needed to determine how to deal, from
a therapeutic point of view, with individuals that have type
D personality, in order to improve their physical and
mental health and to positively influence the progression
of CVD in this group of patients with increased risk.
Without conflicts of interest. No funding was necessary for this
research.
Abbreviations: CAD- coronary artery disease, CVcardiovascular, CVD- cardiovascular diseases, NA- negative affectivity,
OR- Odds Ratio, PCI- percutaneous coronary intervention, RF- risk
factor, SI- social inhibition, TNF-- tumor necrosis factor alpha.
References
1.Bautista LE, Lopez-Jaramillo P, Vera LM, Casas JP, Otero AP,
Guaracao AI. Is C-reactive protein an independent risk factor for
essential hypertension?. J Hypertens 2001; 19:857861.
2.Brook RD, Julius S. Autonomic imbalance, hypertension, and
cardiovascular risk. Am J Hypertens 2000; 13:112S122S.
3.Barth J, Schumacher M, Herrmann-Lingen C. Depression as a risk
factor for mortality in patients with coronary heart disease: A metaanalysis. Psychosom Med 2004; 66:802813.
4.Musselman DL, Evans DL, Nemeroff C. The relationship of
depression to cardiovascular disease: Epidemiology, biology, and
treatment. Arch Gen Psychiat 1998; 55:580592.
5.Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors
on the pathogenesis of cardiovascular disease and implications for
therapy. Circulation 1999; 99:21922217.
6.Yu DSF, Lee DTF, Woo J, Thompson DR. Correlates of psychological
distress in elderly patients with congestive heart failure. J Psychosom
Res 2004; 57:573581.
7.Orth-Gomer K, Horsten M, Wamala SP, Mittleman MA, Kirkeeide R,
Svane B. Social relations and extent and severity of coronary artery
disease. The Stockholm female coronary risk study. Eur Heart J 1998;
19:16481656.
8.Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, Brutsaert
DL. Personality as independent predictor of long-term mortality in
patients with coronary heart disease. Lancet 1996; 347:417421.
9.Denollet J, Vaes J, Brutsaert DL. Inadequate response to treatment in
54
***
55
ORIGINAL ARTICLES
Rezumat:
Pentru a nelege boala maniaco-depresiva, pentru a o
diagnostica cu precizie i pentru a o trata n mod eficient, e
necesara familiarizarea cu ceea ce Kraepelin numea
"caracteristicile comune fundamentale" ale bolii.
Modelele de simptome maniacale si depresive au n mod
clar caracter ciclic, dar aspectele de suprapunere, de
tranziie, precum si cele fluctuante sunt extrem de
importante n descrierea i nelegerea de ansamblu a
bolii. Cursul natural i rezultatele bolii maniacodepresive contribuie la definirea i diferenierea ei de
schizofrenie. Pentru clinician, nelegerea cursului
natural poate sa-l ajute sa rspunda la ntrebrile unui
pacient despre cea mai important estimare a tuturor,
prognosticul: Va reveni, i cnd?
Acknowledgement:
"This paper is published under the frame of European
Social Fund, Human Resources Development Operational
Programme 2007-2013, project no.
POSDRU/159/1.5/S/138776"/ "Acest articol este publicat
prin Fondul Social European, Programul Operational
Dezvoltarea Resurselor Umane 2007-2013, contract nr.
POSDRU/159/1.5/S/138776"
1
Psychiatry MD, PhD Student in Psychiatry, University of Medicine & Pharmacy Iuliu Hatieganu Cluj-Napoca, Romania, 7Ward,Clinical Hospital of
Psychiatry Al. Obregia Bucharest, Romania (madalina.vrabie@yahoo.com)
2
Senior Psychiatry, PhD, Lecturer at Department of Psychiatry, University of Medicine & Pharmacy Carol Davila, Bucharest, Romania,
7Ward,Clinical Hospital of Psychiatry Al. Obregia Bucharest, Romania
3
Senior Psychiatry, PhD, Assistant Professor, Department of Psychiatry, University of Medicine & Pharmacy Carol Davila, Bucharest, Romania,
9Ward,Clinical Hospital of Psychiatry Al. Obregia Bucharest, RomaniaDepartment of Psychiatry, University of Medicine & Pharmacy Carol
Davila, Bucharest, Romania
4
Professor Doctor, Head of Psychiatry Department, University of Medicine & Pharmacy Iuliu Hatieganu Cluj-Napoca,Romania, Second Psychiatric
Clinic, Emergency County Hospital Cluj-Napoca, Romania,
56
Mdlina Vrabie, Victor Marinescu, Anca Talaman,Ioana Micluia: Clinical And Evolutional Aspects In Bipolar Disorder,
Manic Episode (1)
episode)
Grandiosity: high, non-realistic self-trust or
hallucinations
Flight of ideas: speedy thoughts
Activity increase: excessive increase of activity for a goal
in the social or sexual field, school or work
Talkativeness: significantly more talkative than in the
euthymia periods
Indiscretion: dysfunctional activities focused on one's
self such as excessive expenses, unprotected sex with
foreigners and other impulsive behaviours. (16)
Mania is a complex volatile and fluctuating
mixture of symptoms. "The form and ways which mania
manifests are manifold" said Aretaeus (5) nearly 2000
years ago. "Some are cheerful and like to play others
passionate and of destructive type who seek to kill others
as well as themselves". Although classically described as a
state of extraordinary energy and activity, mania can also
present clinically as manic stupor or "catatonia".
Manic mood, frequently characterized as elated and
grandiose, as often as not is riddled with depression, panic
and extreme irritability; mania without significant mixed
features is what is known as classic mania. For years,
mania was differentiated mistakenly from schizophrenia
because it reputedly lacked a thought disorder. Now it is
recognized as an often floridly psychotic condition.
Manic episodes differ from person to person and in the
same individual from time to time, although Falret (17, 18)
and Kraepelin (1) noted a tendency for constancy in
symptom patterns across episodes in the same individual.
Wellner and Marstal (19) reporting on a study of 279
manic episodes in 221 patients, concluded that atypical
attacks are followed by atypical, and typical by typical
significantly more often than not (P = 0.002), indicating
the patients' inclination to reproduce the type of their
psychoses". Beigel and Murphy (20) found that patients
with multiple manic attacks tended to show similar
behavior and mood patterns during subsequent episodes.
Two more recent studies (21, 22) demonstrated that manic
and mixed episodes show diagnostic stability over time;
the interepisode stability of depressive mixed states, while
significant, is much less pronounced than is the case for
manic states (23).
Goodwin and Jameson (15) wrote that the symptomatic
profile of catatonia is extremely consistent over episodes,
whereas Casidy and colleagues (24), who evaluated 77
bipolar patients during two distinct manic episodes for 2
years, concluded that manic symptomatology generally
remains consistent from one episode to the other. More
precisely, they found out that the severity of mania,
dysphoria, hedonic activation, psychosis and irritable
aggression tend to correlate to each other over episodes,
but not psychomotor symptoms. Regardless of the degree
of constancy of the clinical picture across attacks, it is
clear that symptoms vary widely during any given manic
episode as it progresses through different stages. These
stages, characterized by Carlson and Goodwin (25), begin
with elation or irritability, evolve into a more severe form
of arousal and hyperactivity escalate, and culminate in
floridly psychotic disorganization.
Research (15) on mood symptoms in mania, shows that
most patients, on average, are depressed (46 percent) or
labile (49 percent) nearly as often as they are euphoric (63
percent) or expansive (60 percent); they are irritable (71
58
Mdlina Vrabie, Victor Marinescu, Anca Talaman,Ioana Micluia: Clinical And Evolutional Aspects In Bipolar Disorder,
Manic Episode (1)
may be increased by a relatively small number of patients
having, for example, a tardy onset. When reporting
average age to onset, it usually belongs to the early
twenties.
Some of the variations of individual studies are related to
different criteria for onset. In general, the age when the
first symptoms occur is younger than the age when
patients meet the diagnostic criteria, and the age of the first
clinical contact is usually higher (the first hospitalization
is a measure that says very little about the onset age).
Some studies used the age upon the first clinical contact
based on the assumption that the information about initial
symptoms might be too imprecise.
Indeed the literature is consistent in finding a significant
time gap between onset of the illness and the first
treatment. Meeks (42) found that mean age at first
symptoms in a bipolar and unipolar population was almost
6 years younger than age at first treatment. A demographic
study of the first 261 patients in the Stanley Bipolar
Foundation (which may represent patients on the more
severe end of the spectrum) revealed an 8-year difference
between age at first diagnostic and age at first medical
treatment (22.9 and 30.4 years, respectively), whereas age
at first symptoms was only 2 years before age at diagnostic
onset (40). In a Stanley Foundation recruitment survey
administered by Kupfer and colleagues (43), more than 50
percent of a large bipolar sample indicated that they had
received no treatment for their first affective episode.
Thus it is to be expected that age at first treatment is a weak
indicator of onset.
The lower age at onset is reported in more recent studies.
Researchers have advanced several hypotheses to explain
this reduction in age at onset. Changes in nosology and
illness definition could be a partial explanation.
The increasing use of antidepressants and stimulants in
teenagers and children may help induce the onset of
bipolar disorder at an earlier age in those already
susceptible (44, 45, 46). This phenomenon might be
consistent with what we know about the effect of
antidepressants on mania induction and cycle
acceleration, but more research is necessary to draw a
solid conclusion.
The switch into mania or hypomania may be the
consequence of active treatment for bipolar depression,
some drugs, such as tricyclic antidepressants and
venlafaxine have bigger chances to cause the switch than
others. Bu this increase of the switch rate might not be
visible until after 10 weeks of treatment. To notice this
switch, studies should include scales to define the event
phenomenology (e.g. hypomania or mania) and its
severity. These may be best used immediately after the
clinical finding of switch occurrence. Long-term
treatment is usually necessary in the bipolar disorder. (47)
Similar to the association of antidepressants is the
hypothesis that the increased use of recreational drugs and
alcohol among the youth contributes to the decrease of age
at onset. Here, again, consistent evidence is missing and it
is difficult to establish a unidirectional association
between the onset of affective symptoms and the onset of
drug consumption. (48)
Very late onset of the bipolar affective disorder (e.g. after
60) has been generally considered rare (49, 50). Patients
with very late onset are less likely to have a family history
60
61
Mdlina Vrabie, Victor Marinescu, Anca Talaman,Ioana Micluia: Clinical And Evolutional Aspects In Bipolar Disorder,
Manic Episode (1)
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ORIGINAL ARTICLES
Rezumat
Introducere: n Psihiatria Copilului i Adolescentului
tulburarile somatice sunt pe ct de frecvente pe att de
dificil de diagnosticat. Copiii i familiile lor ajung frecvent
de la un specialist la altul n cutarea unui diagnostic i a
unei rezolvri.
Obiectivul studiului a fost de a analiza ponderea tulburrii
psihosomatice la pacienii neuropsihiatrici, pentru
idenficarea factorilor de predicie pentru un prognostic
bun i pentru a verifica impactul tratamentului psihiatric
asupra rezultatului clinic.
Materiale i metode: Am realizat un studiu retrospectiv
observaional de tip serii de cazuri n cadrul
Departamentului de Neuropsihiatrie a Spitalului Clinic de
Urgen pentru Copii "Sf Ioan" din Galati. Au fost inclui
548 pacieni ntre 6 i 18 ani. S-a realizat o baza de date in
care am inclus urmtorii parametri: datele sociodemografice, tipul consultului (interdisciplinar sau
solicitat de familie), date clinice (semne i simptome de la
prezentare, durata de la debutul simptomelor la
prezentare) i tipul de tratament i evoluia clinic. Pentru
analiza datelor calitative s-au alcatuit tabele de
contingenta calculate cu testul Chi 2 sau Testul exact al lui
Fisher iar pentru datele cantitative s-a folosit Testul t test.
S-a folosit un nivel de semnificatie mai mic de 0,05.
Rezultate: Un total de 548 pacieni diagnosticati in
perioada 1997-2003 au fost inclui. Vrsta medie a fost de
12.93+/-2.74 ani iar 69,53% au fost de sex feminin. O
parte important din eantion, 87,04% dintre pacieni a
fost trimisi de un medic pediatru, iar n 12,96% din cazuri
familia a fost cea care a solicitat consultul. Cel mai
frecvent simptom la prezentare la copii a fost cefaleea.
Concluzie: Abordarea multidisciplinar i complianta la
tratament s-au dovedit a fi factori care prezic un rezultat
pozitiv.
Cuvinte cheie: Tulburare somatoforma, evaluare,
tratament, prognostic
1
Child and Adolescent Neuropsychiatry Specialist, MD, PhDs, Neuropsychiatry Department, St Ioan Emergency Hospital for Children, Galati,
Romania
2
Child and Adolescent Psychiatry Specialist, MD, PhDs, Clinical Psychology Department, Carol Davila University of Medicine and Pharmacy,
Bucharest, Romania
3
Child and Adolescent Psychiatry Resident, MD, PhDs, Child and Adolescent Psychiatry Department, Prof. Dr. Al. Obregia Clinical Hospital of
Psychiatry
4
Child and Adolescent Psychiatry Specialist, Univ. Assistant, MD, PhD, Child and Adolescent Psychiatry Department, Carol Davila University of
Medicine and Pharmacy
4.Senior Child and Adolescent Psychiatrist, MD, PhD, Head of Child and Adolescent Psychiatry Department, Carol Davila University of Medicine and
Pharmacy, Bucharest, Romania
Corresponding author:
Cristina Petrescu-Ghenea
Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, Berceni Road, No. 4, Bucharest, Romania, 021/3344266; e-mail:
cristina.petrescughenea@gmail.com
Spitalul Clinic de Urgen pentru Copii "Sf. Ioan", Centrul de Sanatate Mintala,
Str. Gheorghe Asachi nr.2, Galai.
63
Marcela Campean, Carmen Trutescu, Cristina Petrescu-ghenea, Alecsandra Irimie-ana, Cristina G. Anghel, Liana
Kobylinska, Iuliana Dobrescu: Somatization Disorders In Children And Adolescents - A Local Perspective From The
Galati County
INTRODUCTION
Although quite common in children and
adolescents, somatoform disorders have been given little
attention by researchers in this population. Somatoform
disorders are characterised by physical symptoms or
complaints about pain that cannot be explained by a
medical problem or effect of a substance. (1) Their
symptoms are not intentionally produced or faked by the
child and are believed to be associated with psychological
factors like strong emotions or situations that threaten the
individual's physical or psychological integrity.
Behavioral or emotional problems are more likely to be
observed in children that exhibit
psychosomatic
symptoms (2).
ICD-10 subdivides these disorders into
somatization disorder, undifferentiated somatoform
disorder, hypochondriacally disorder, somatoform
autonomic dysfunction, persistent somatoform pain
disorder, and other somatoform disorders. (3) Of all these
somatoform disorders, the most commonly seen in
children and adolescents is persistent somatoform pain
disorder. In DSM-5, somatoform disorders are called
somatic symptom and related disorders. Somatization
disorder and undifferentiated somatoform disorder from
the DSM-IV-TR were combined to become somatic
symptom disorder, a diagnosis which no longer requires a
specific number of somatic symptoms. (4)
The prevalence of somatoform complaints in 2-17
years old population is 8-24% depending also on study
design. (5-9) In a general population study, somatic
complaints were found in 11% of girls, and 4% of boys.
(10)
Psychosomatic symptoms in adolescents
represent a transient response to stress and conflict and
usually are the beginning of psychopathological conditions
that can frequently lead to depression and anxiety in
adulthood. Lieb and Zimmermann in 2002 concluded that
somatizations are primary forms of coping strategies. (11)
Also several researchers, as Maloney in 1980 and
later on, Lieb in 2007, have noted that children with
somatoform symptoms are directly influenced by familial
climate and they often shape their symptoms after family
members or close friends. (12,13)
In children or adolescents, psychosomatic
symptoms are difficult to evaluate - children are taken by
their families to a specialist, in search of diagnosis and
relief and are usually characterized by a lack of adherence
to psychiatric medication and psychotherapy. Stigma can
play a big part in this process, especially because the
diagnosis of such disorders is complex as they may appear
as medical conditions. Patients with these disorders
typically present to general medical settings or in pediatrics
departments rather than directly to mental health settings.
Another factor in the delay of evaluation and
intervention for somatic disorders in pediatric population
can be the lack of coherence in the multidisciplinary team
that should cooperate to better solve these cases.
Specialists that form these teams often do not fully
understand and respect the role of the other members of the
team. For example, once a child is referred to the mental
health department he can still remain under symptomatic
treatment in the pediatrics department, even if there is no
evidence of organic disease. This attitude can make
64
Marcela Campean, Carmen Trutescu, Cristina Petrescu-ghenea, Alecsandra Irimie-ana, Cristina G. Anghel, Liana
Kobylinska, Iuliana Dobrescu: Somatization Disorders In Children And Adolescents - A Local Perspective From The
Galati County
A longer than 6 months duration of symptoms had been
found in patients exhibiting polysymptomatic accuses, as
well as in those whose parents had a chronic illness (chisquare statistic is 28.05, p< 0.01). Patients coming from a
harmonious family environment generally had a total
duration of symptoms after diagnosis less than 6 months.
As far as the rest of the patients were concerned, namely
those coming from single parent families and families
where tensions were reported, symptoms were found to
last for more than 6 months (The chi-square statistic is
33.09, p< 0.01).
DISCUSSIONS
The mean age and sex distribution, with the
majority of patients referred for somatic symptoms being
females in their teens and almost equal proportions for
younger boys and girls is concordant to the findings in
Campo's study from 1999 by which he tried to classify
somatic disorders in the pediatric population analyzing
data from 21065 children. (14) Somatic symptoms
generally occur more commonly in females than males
with a ratio of 5:1, epidemiology that is similar to the
gender proportion of subjects in our study. (15) It might be
that a smaller sample had a little influence on the
proportion found in our study (Female: Male=3.48:1), this
also being the proportion found in adolescents and not all
the sample. A sensibly higher number of male patients
during the interval between 6 and 8 years of age, could be
attributed to bigger difficulties in boys during the
beginning of school that coincides with the specified age
period. A 2011 report of the United States National Center
for Education Statistics informs that boys are 30 percent
more likely to flunk or drop out of school. (16)
The high rate of patients referred by a
pediatrician (87.04%) is in total agreement with general
data about somatization disorders. Presenting as organic
disease, parents bring their children into mental health
departments only after all objective causes for those
symptoms could be ruled out.
66
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***
67
ORIGINAL ARTICLES
Rezumat
Background:Desi majoritatea ghidurilor terapeutice
recomand utilizarea antipsihoticelor atipice (AA) ca
monoterapie n managementul episodului psihotic acut al
pacienilor cu schizofrenie, att n SUA precum si n
Europa Occidental, deseori acesti pacieni sunt tratai cu
antipsihotice de prim generaie, combinaie de
antipsihotice (polifarmacie) ori doze subterapeutice de
AA. Comparativ, exist mai puine date referitoare la
managementul acestor pacieni n Europa Central si de
Est.
Obiective: Evaluarea discrepanelor ntre practica clinic
si ghidurile terapeutice n managementul episodului
psihotic acut la pacienii cu schizofrenie.
Metod: Studiu non-intervenional, multinaional,
multicentric (RECONNECT-S GAMMA) n scopul
descrierii managementului episodului psihotic acut la
pacienii cu schizofrenie spitalizai pentru un astfel de
episod. Pacienii studiai (vrsta 18 ani) au avut o vizit
de studiu n ziua externrii. Au fost colectate date
demografice si date referitoare la tratamentul antipsihotic
si medicaia concomitent administrate n perioada
spitalizrii precum si recomandrile la externare.
Rezultate: Din 496 pacieni, 49 (9,9%) au fost tratai cu
AA n monoterapie si 418 (84,3%) au fost tratai cu terapie
de combinaie. Pe ansamblu cele mai folosite
medicamente au fost quetiapina oral (n=129; 27,4%),
risperidona oral (n=95; 20,2%), olanzapina oral
(n=104; 22,1%) si clozapina oral (n=73; 15.5%), cu
variaii de administrare ntre ri. La externare unui
numr semnificativ (n=373; 75.2%) de pacieni (n=373;
75,2%) i-a fost prescrise AA ca medicaie de ntreinere, un
numr de 335 (69.9%) primind aceeasi medicaie cu care
au fost tratai pe perioada spitalizrii.
Concluzii: Practica clinic obisnuit n Eudopa Central
si de Est difer fa de ghidurile terapeutice, un numr mai
mic de pacieni cu schizofrenie primind AA ca
monoterapie pentru episodul psihotic acut.
Cuvinte cheie
Schizofrenie; Europa Centrala si de Est; antipsihotic
atipic; episod psihotic acut; ghiduri de tratament
Prof. Dr. Alexandru Obregia Clinical Psychiatry Hospital, Bucharest, Sos. Berceni nr. 10, Sector 4, Bucharest, Romania
Department of Psychiatry and Narcology, Riga Stradina University, 2 Tvaika Street, Riga, LV-1005, Latvia
Department Psychiatry, Mental Hygiene and Addictology, Petz Aladr County Teaching Hospital, 9023 Gyr, Vasvry Pl u. 2-4, Hungary
Corresponding author
Professor Dan Preliceanu
Address: Prof. Dr. Alexandru Obregia Clinical Psychiatry Hospital, Bucharest, Sos. Berceni nr. 10, Sector 4, Bucharest, Romania
Tel./Fax: +40-21-334.84.06
Email: prelipceanudan@yahoo.com
2
68
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Radu Teodorescu, Elmars Rancans, Gabor Feller, Dan Prelipceanu: A Non-interventional Study To Observe Real-life
Usage Of Atypical Antipsychotics In The Acute Inpatient Management Of Schizophrenia In Central And Eastern Europe
were hospitalised due to an acute psychotic episode. The
study required that the subject had the ability to
understand and comply with the requirements of the study,
as judged by the investigator. Written informed consent
was obtained from the subject and/or his/her legal
representative (as per local regulatory requirements).
Ethical approval was obtained for each study site in
Hungary and Latvia. Only health authority approval was
required in Romania; this was obtained from the National
Medicine and Medical Devices Agency.
Exclusion criteria consisted of current participation in a
clinical trial or previous enrolment in the current study (in
the case of re-hospitalisation).
Study Objectives
The primary objective of the study was to describe the use
of AAP in subjects with schizophrenia during
hospitalisation due to an acute psychotic episode, by
evaluation of drug, dose, mode and length of
administration of the medication.
Secondary objectives included: evaluation of the use of
AAP as monotherapy and the use of combinations of
antipsychotics during the hospitalisation period;
investigation of the main criteria used for selection of an
antipsychotic to treat acute episodes of schizophrenia;
description of the use of psychometric scales to evaluate
the disease symptoms during the hospitalisation period;
investigation of the use of concomitant psychiatric
medications (other than atypical antipsychotics) during
hospitalisation; the correlation between antipsychotic
medication used during hospitalisation and maintenance
therapy recommended upon discharge.
Safety
This non-interventional study was designed without a
specific safety objective, therefore no safety data were
pro-actively collected. Spontaneously-mentioned safety
events were reported as required by post-marketing
pharmacovigilance regulations.
Statistical Analyses
A descriptive analysis approach (including frequency
tables) was used owing to the non-interventional design of
the study. As appropriate, a two-sided 95% confidence
interval was obtained for the population estimation of the
variables. All calculations and summaries were produced
using SAS Version 9.2 (SAS 2009), with medications
coded using the WHO drug dictionary, version 12.1.
Results
Patient demographics and baseline characteristics
The study was conducted between December 2011 and
May 2012. Patient demographics are shown in Table 1. Of
the 496 subjects enrolled in the study, all met the inclusion
criteria and none of the exclusion criteria applied to these
subjects; 243 participants (49.0%) were male. Participants
had a mean age standard deviation (SD) of 43.5 11.58
years, and a mean number of years of education SD of
11.6 2.64. All subjects were Caucasian (race data
missing for one subject) and the majority were in receipt
of sickness pension (61.7%), unemployed (13.1%), or
retired (10.7%). Over 40% of study subjects reported
psychosocial problems and approximately 8% had made
one or more suicide attempt(s).
Overall, 34.1% of patients had concurrent psychiatric
conditions in addition to their primary schizophrenia
diagnosis (Table 2). In Hungary, 76.5% of patients were
reported to have a concomitant psychiatric condition,
compared with just 6.9% and 10.4% of patients from
Latvia and Romania, respectively. One hundred and fifty
70
Radu Teodorescu, Elmars Rancans, Gabor Feller, Dan Prelipceanu: A Non-interventional Study To Observe Real-life
Usage Of Atypical Antipsychotics In The Acute Inpatient Management Of Schizophrenia In Central And Eastern Europe
Post-discharge prescription patterns in Romania and
Latvia were highly similar to the hospitalisation
prescription pattern but were markedly different in
Hungary; in Latvia and Romania 99.0% and 83.4% of
patients respectively, were prescribed the same
medication at discharge as during hospitalisation, while in
Hungary only 52.5% were. In Romania it is customary to
continue in-hospital medication patterns upon discharge
unless there is good reason to add or remove a medication.
As a result, prescription patterns would generally not be
expected to differ. However in Hungary, on discharge
patients commonly return to their own doctor, who may
then use his or her own personal experience to determine
the appropriate treatment once the acute episode has been
controlled.. This can lead to a change in patients'
medication in terms of antipsychotic and/or dose, or
switching to monotherapy. These findings illustrate
further how individualised treatment strategies and
common clinical practice can influence the treatment of
acute episodes of schizophrenia, leading to the observed
differences between different countries. Given the nonrandomised nature of the current study, the above findings
should be interpreted conservatively, and additional
studies may be required to further elucidate the
prescribing practices within these countries.
In conclusion, this study indicated that although the
majority of subjects with schizophrenia were treated with
AAP for acute psychotic episodes during hospitalisation,
they were commonly used in combination with other
psychiatric medications, rather than as monotherapy.
These treatment practices are contrary to current guideline
recommendations and further studies to investigate the
resulting outcomes for patients, and whether such
disparities exist in other countries, are warranted.
Table 1. Patient demographics
Variable
Gender
Age (years)
Total number of
education years
(years)
Current
employment
status
Suicide attempts
during last two
years
Psychosocial
problems
SD=Standard deviation
72
Male
Female
n
Mean
SD
N
Mean
SD
Employed
Self-employed
Unemployed
Sickness
pension
Retired
Student
Other
Unknown
Missing
0
1-2
3 or more
Unknown
No
Yes
Unknown
Hungary
(N=183)
n (%)
75 (41.0)
108 (59.0)
181
46.4
11.63
171
11.1
2.84
29 (15.8)
1 (0.5)
22 (12.0)
89 (48.6)
Latvia
(N=102)
n (%)
74 (72.5)
28 (27.5)
92
40.9
11.96
86
11.9
2.06
4 (3.9)
4 (3.9)
15 (14.7)
73 (71.6)
Romania
(N=211)
n (%)
94 (44.5)
117 (55.5)
209
42.1
10.87
181
12.0
2.63
7 (3.3)
0 (0.0)
28 (13.3)
144 (68.2)
Overall
(N=496)
n (%)
243 (49.0)
253 (51.0)
482
43.5
11.58
438
11.6
2.64
40 (8.1)
5 (1.0)
65 (13.1)
306 (61.7)
39 (21.3)
0 (0.0)
3 (1.6)
0 (0.0)
0 (0.0)
152 (83.1)
20 (10.9)
5 (2.7)
6 (3.3)
89 (48.6)
89 (48.6)
5 (2.7)
1
0
4
0
1
93
7
2
0
63
38
1
13 (6.2)
0 (0.0)
14 (6.6)
0 (0.0)
5 (2.4)
186 (88.2)
5 (2.4)
1 (0.5)
19 (9.0)
115 (54.5)
92 (43.6)
4 (1.9)
53 (10.7)
0 (0.0)
21 (4.2)
0 (0.0)
6 (1.2)
431 (86.9)
32 (6.5)
8 (1.6)
25 (5.0)
267 (53.8)
219 (44.2)
10 (2.0)
(1.0)
(0.0)
(3.9)
(0.0)
(1.0)
(91.2)
(6.9)
(2.0)
(0.0)
(61.8)
(37.3)
(1.0)
Concurrent secondary
psychiatric conditions
[a],
n (%)
General medical
conditions, n (%)
No
Hungary
(N=183)
43 (23.5)
Latvia
(N=102)
95 (93.1)
Romania
(N=211)
189 (89.6)
Overall
(N=496)
327 (65.9)
Yes
140 (76.5)
7 (6.9)
22 (10.4)
169 (34.1)
No
Yes
Missing
96 (52.5)
86 (47.0)
1 (0.5)
85 (83.3)
16 (15.7)
1 (1.0)
150 (71.1)
55 (26.1)
6 (2.8)
331 (66.7)
157 (31.7)
8 (1.6)
123 (67.2)
56 (54.9)
153 (72.5)
332 (66.9)
[a] These subjects had comorbid psychiatric conditions (with primary diagnosis of schizophrenia).
Table 3: Length of hospital stay (days)
Mean
SD
Min
Max
95% CI*
Hungary
(N=183)
31.3
48.82
2.0
500.0
[24.2, 38.5]
Latvia
(N=102)
37.0
14.05
7.0
84.0
[34.3, 39.8]
Romania (N=211)
22.6
31.41
3.0
383.0
[18.3, 26.8]
Overall
N=496
28.8
36.99
2.0
500.0
[25.5, 32.0]
Hungary
(N=183)
n (%)
178 (97.3)
[93.7, 99.1]
Latvia
(N=102)
n (%)
101 (99.0)
[94.7,100.0]
Romania
(N=211)
n (%)
200 (94.8)
[90.9, 97.4]
Overall
(N=496)
n (%)
479 (96.6)
[94.6, 98.0]
Quetiapine
Oral Route
Mean (mg)
SD
Median
Min, Max
Risperidone
Oral Route
Mean (mg)
SD
Median
Min, Max
IM Route
Mean
SD
Median
Min, Max
Olanzapine
Oral Route
42 (24.4)
42 (24.4)
583.9
222.36
600.0
75.0, 800.0
31 (18.0)
20 (11.6)
3.9
1.48
4.0
1.0, 6.0
11 (6.4)
37.1
19.10
50.0
4.0, 50.0
49 (28.5)
42 (24.4)
36 (35.6)
36 (35.6)
608.3
237.10
600.0
100.0, 1100.0
28 (27.7)
28 (27.7)
5.1
1.66
4.5
2.0, 8.0
0 (0.0)
----12 (11.9)
11 (10.9)
51 (25.9)
51 (25.9)
611.8
207.51
600.0
200.0, 1200.0
64 (32.5)
47 (23.9)
4.7
2.17
4.0
2.0, 12.0
17 (8.6)
11.0
15.76
2.6
1.7, 50.0
53 (26.9)
51 (25.9)
129 (27.4)
129 (27.4)
601.7
219.51
600.0
75.0, 1200.0
123 (26.2)
95 (20.2)
4.7
1.93
4.0
1.0, 12.0
28 (6.0)
21.2
21.23
5.3
1.7, 50.0[a]
114 (24.3)
104 (22.1)
73
Radu Teodorescu, Elmars Rancans, Gabor Feller, Dan Prelipceanu: A Non-interventional Study To Observe Real-life
Usage Of Atypical Antipsychotics In The Acute Inpatient Management Of Schizophrenia In Central And Eastern Europe
Mean (mg)
SD
Median
Min, Max
IM Route
Mean
SD
Median
Min, Max
Clozapine
Oral Route
Mean (mg)
SD
Median
Min, Max
Amisulpride
Oral Route
Mean (mg)
SD
Median
Min, Max
Aripiprazole
Oral Route
Mean (mg)
SD
Median
Min, Max
Ziprasidone
Oral Route
Mean (mg)
SD
Median
Min, Max
Paliperidone
Oral Route
Mean (mg)
SD
Median
Min, Max
Sertindole
Oral Route
Mean (mg)
SD
Median
Min, Max
17.4
5.42
20.0
5.0, 30.0
7 (4.1)
165.9
142.84
210.0
15.0, 300.0[a]
17.3
4.67
20.0
10.0, 20.0
0 (0.0)a
-----
14.9
6.44
15.0
5.0, 30.0
2 (1.0)
210.0
275.77
210.0
15.0, 405.0[b]
29 (16.9)
29 (16.9)
228.4
154.65
200.0
25.0, 550.0
10 (5.8)
10 (5.8)
390.0
159.51
350.0
200.0, 600.0
26 (15.1)
26 (15.1)
24.2
7.44
30.0
15.0, 30.0
3 (1.7)
3 (1.7)
106.7
41.63
120.0
60.0, 140.0
14 (8.1)
14 (8.1)
10.7
1.94
12.0
6.0, 12.0
0 (0.0)
0 (0.0)
-----
32 (31.7)
32 (31.7)
184.3
176.59
162.5
10.0, 900.0
11 (10.9)
11 (10.9)
818.2
244.21
800.0
400.0, 1200.0
6 (5.9)
2 (2.0)
22.5
10.61
22.5
15.0, 30.0
7 (6.9)
6 (5.9)
103.3
29.44
100.0
80.0, 160.0
0 (0.0)
0 (0.0)
----7 (6.9)
7 (6.9)
18.7
2.21
20.0
15.0, 20.0
12 (6.1)
12 (6.1)
379.2
119.58
400.0
200.0, 500.0
22 (11.2)
22 (11.2)
581.8
230.19
600.0
200.0, 1000.0
8 (4.1)
8 (4.1)
14.1
3.76
15.0
7.5, 20.0
4 (2.0)
4 (2.0)
105.0
50.0
110.0
40.0, 160.0
0 (0.0)
0 (0.0)
----1 (0.5)
1 (0.5)
12.0
-12.0
12.0, 12.0
16.2
5.96
20.0
5.0, 30.0
9 (1.9)
175.7
158.71
210.0
15.0,
(300/405.0)[c]
73 (15.5)
73 (15.5)
233.9
171.86
200.0
10.0, 900.0
43 (9.1)
43 (9.1)
597.7
263.21
1200.0
200.0, 1200.0
40 (8.5)
36 (7.7)
21.9
7.98
17.5
7.5, 30.0
14 (3.0)
13 (2.8)
104.6
35.73
100.0
40.0, 160.0
14 (3.0)
14 (3.0)
10.7
1.94
12.0
6.0, 12.0
8 (1.7)
8 (1.7)
17.9
3.14
20.0
12.0, 20.0
Note: Average daily dose for subjects with dose frequency recorded as PRN (as needed) were calculated using once per
day. If dose frequency was missing, once daily was assumed unless otherwise stated. If route of administration was
missing, oral route was assumed.
Min=minimum; max=maximum; SD=standard deviation.
[a] Recommended maximum dose administered every 2 weeks
[b] Recommended maximum dose administered every 4 weeks
[c] Administration of 300 mg and 405 mg of olanzapine represents two different dosing schedules. Administration of
300 mg depot injection every 2 weeks (in Hungary) is equivalent to a 20 mg daily dose, whereas administration of 405
mg depot injection every 4 weeks (in Romania) is equivalent to a 10 mg daily dose.
74
Hungary
(N=183)
n (%)
178 (97.3)
Latvia
(N=102)
n (%)
101 (99.0)
Romania
(N=211)
n (%)
200 (94.8)
Overall
(N=496)
n (%)
479 (96.6)
21 (11.5)
6 (3.3)
2 (2.0)
3 (2.9)
26 (12.3)
3 (1.4)
49 (9.9)
12 (2.4)
151 (82.5)
96 (94.1)
171 (81.0)
418 (84.3)
0 (0.0)
138 (75.4)
13 (7.1)
19 (18.6)
24 (23.5)
53 (52.0)
1 (0.5)
145 (68.7)
25 (11.8)
20 (4.0)
307 (61.9)
91 (18.3)
4 (2.2)
0 (0.0)
0 (0.0)
4 (2.2)
1 (1.0)
0 (0.0)
0 (0.0)
1 (1.0)
9 (4.3)
1 (0.5)
0 (0.0)
8 (3.8)
14 (2.8)
1 (0.2)
0 (0.0)
13 (2.6)
1 (0.5)
0 (0.0)
2 (0.9)
3 (0.6)
Hungary
(N=183)
n (%)
Latvia
(N=102)
n (%)
Romania
(N=211)
n (%)
Overall
(N=496)
n (%)
96 (52.5)
101 (99.0)
176 (83.4)
373 (75.2)
[45.0, 59.9]
[94.7,100.0]
[77.7, 88.2]
[71.2, 78.9]
88 (49.4)
90 (50.6)
83 (82.2)
18 (17.8)
164 (82.0)
36 (18.0)
335 (69.9)
144 (30.1)
[a] Normal approximation for the proportion of the population with atypical antipsychotic medication as
maintenance therapy.
[b] Denominator is the number of subjects treated with atypical antipsychotic medication during hospitalisation.
References
(1) World Health Organization. Mental Health: Schizophrenia.
http://www who int/mental_health/management/schizophrenia/en/
2013. Available from http://www.who.int/mental_health/management/
schizophrenia/en/, accessed February 2014.
(2) McGrath J, Saha S, Chant D, Welham J. Schizophrenia: a concise
overview of incidence, prevalence and mortality. Epidemiol Rev 2008;
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(3) Predescu V et al. Evolutia morbiditatii intr-un grup de populatie
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(4) Pulmanis T, Pelne A, Taube M. Psihisk veselba Latvij 2011. gad
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(5) Ayuso-Mateos JL. Global burden of schizophrenia in the year 2000:
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(11) Latvijas Psihiatru Asiciacijas. Depresijas norise un rstanas
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76
***
ORIGINAL ARTICLES
Rezumat :
Introducere.O serie de cercetri internaionale au
evideniat riscul ocupaional al mecanicilor de locomotiv
de a fi expui la incidente feroviare cu potenial traumatic
i de a dezvolta simptome de stres posttraumatic i alte
tulburri comorbide.Dei frecvena incidentelor
,,persoan sub tren este crescut, puini dintre mecanicii
de locomotiv expui la acestea, raporteaz ulterior
simptome de stres posttraumatic.
Obiective. Scopul studiului actual este de a identifica ce
anume i difereniaz pe mecanicii cu simptome de stres
posttraumatic cauzate de implicarea n incidentele
traumatice i de a explora diferenele individuale ca
factori de risc pentru dezvoltarea ulterioar a
simptomelor postraumatice.
Metode. 129 de mecanici de locomotiv expui la
incidente PST au completat un chestionar demografic,
Scala Revizuit a Impactului Evenimentelor, Indexul Strii
generale de sntate, Inventarul cogniiilor
posttraumatice i Inventarul distresului peritraumatic.
Rezultate.Analiza statistic a datelor a evideniat
diferene importante privind cogniiile posttraumatice i
impactul emoional peritraumatic al incidentelor PST
ntre mecanicii de locomotiv cu simptome de stres
posttraumatic i cei ce nu raporteaz ulterior simptome. n
particular, am identificat c relaia dintre distresul
peritraumatic i simptomele de stres traumatic este
mediat parial de auto-blamare.
Concluzii. Rezultatele obinute evideniaz necesitatea de
a include factorii de risc cognitivi i emoionali n
programele de prevenie i intervenie specifice pentru
mecanicii de locomotiv implicai n incidentele PST.
Cuvinte cheie: trauma, tulburarea de stres posttraumatic,
factori de risc, mecanici de locomotiv, incidente
,,persoan-sub-tren
INTRODUCTION
Post traumatic stress disorder (PTSD) represents
the most investigated form of a posttraumatic reaction.
According to the DSM IV TR (2000), the current standard
for diagnosing mental disorders, PTSD is characterized by
three distinct types of symptoms including reexperiencing of the event, avoidance patterns and
persistent hyperarousal(1). Although epidemiological
studies highlight that most people are confronted at least
once in their lifetime with events of traumatic intensity,
prevalence of posttraumatic stress disorder in the general
population is relatively low (2).
Thus, traumatic exposure is neccesary, but not
1
PhD student, psychologist, Trafic Safety Psychological Laboratory at CF Clinical Hospital, Campeni street, no 3 A, Cluj-Napoca, Romania,
correspondence e-mail: cdoroga@yahoo.com
2
PhD, University Professor, Faculty of Psychology and Educational Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
77
Corina Doroga, Adriana Bban: Cognitive And Emotional Correlates Of Posttraumatic Stress Symptoms In Train Drivers
Exposed To Work Trauma
recomandations strongly suggest the need to identify risk
pathways or mechanisms, underlying their relationship to
outcome variables (5). Diversity of identified risk factors
and different trajectories of vulnerability are proof of the
fact that one cannot evaluate trauma reaction outside of
the specific context of confrontation.
Person-under-train (PUT) accidents are serious
rail incidents, resulting in violent death or injury of
persons, because of accidentally or intentionally falling in
front of the moving train (6). They consist of railway
suicides, accidents or collisions of vehicles with the
locomotive at level crossings. Being frequently exposed
to these work incidents, train drivers are susceptible of
developing posttraumatic reactions, and researchers have
tried to identify risk factors that raise train drivers'
vulnerability to trauma.
Most studies investigate circumstantial factors
that may influence train drivers's response to trauma, like
frequent exposure to job related incidents or severity of
their consequences (7,8). Studies support the need to
investigate the role of individual differences in the
development and maintenance of PTSD symptoms in train
drivers involved in PUT incidents(9,10).
Current perspective on the development and
persistence of PTSD symptoms emphasizes the role of
cognitive appraisal of the traumatic experience as a
fundamental mediator in the posttraumatic adaptation
process (11). Cognitive models of PTSD (12-14) assert
that dealing with trauma produces alterations in the
generic cognitive schemas about the world, self and
others. Exposed persons' perspective and belief system is
being affected by the traumatic event, so that the world is
perceived to be unsafe and threatening, and the self is seen
as lacking the resources and skills needed to cope with the
adversive environment (14,15).
Presence of these negative beliefs about oneself
and the world, as a result of a traumatic encounter,
represents the essential vulnerability factor for specific
PTSD symptoms. Catastrophic interpretation that these
central negative beliefs generate, involves retrospective
exaggeration of traumatic events, and/or the permanent
appraisal of being at risk to be exposed to a new
trauma(14).
Cognitive distortions about the world and the self
proved to be strong predictors of PTSD diagnosis, as they
can discriminate between all trauma exposed individuals,
those that developed clinically significant symptoms
(16,17). Studies in samples with various types of trauma
provide strong empirical support for the relationship
between the altered beliefs about the self and the world
and
the frequency and severity of posttraumatic
symptoms (16-19). Also, challenging and modifing these
beliefs in cognitive-behavioral therapy for traumatised
people has been effective in reducing specific symptoms
PTSD (20).
In terms of work related trauma confrontation
one study found that posttraumatic stress was predicted by
pretrauma catastrophic thinking in a sample of firefighters
exposed to on the job traumatic incidents (21). This risk
factor may be essential for train drivers as well, because,
although most of them are confronted with at least one
PUT incident during their years of duty, studies show that
just a few develop persistent PTSD symptoms (9).
According to a french study(7), the traumatic potential of
78
Corina Doroga, Adriana Bban: Cognitive And Emotional Correlates Of Posttraumatic Stress Symptoms In Train Drivers
Exposed To Work Trauma
In line with findings from other studies, current findings
support the positive association of posttraumatic
cognitions about the self (r = 0.45, p = 0.01) and the world
(r = 0.27, p = 0.01) and reported PTSD symptoms. The
more negative the individual views the self and the world,
the higher the level of posttraumatic symptoms he reports.
When considering effect size of significant correlations,
the relationship between negative cognitions about the
self and the frequency of PTSD symptoms has the
strongest pragmatical impact (r = 0,20) among the three
types of posttraumatic cognitions. Perception of self as
incompetent, or lacking ability to cope with trauma may
be a relevant predictor of persistence of PTSD symptoms
for train drivers involved in PUT incidents.
Also self-blaming cognitions were significantly
positively associated with PTSD symptoms (r = 0.38, p =
0.01). The determination coefficient for this relationship
also demonstrates a strong effect size (r= 0,14). If the
train driver considers himself blameworthy for causing
the incident, the level of PTSD symptoms he reports will
be greater. Relationship with this risk factor is particularly
relevant because the context of PUT incidents leaves room
for negative interpretation on the adequacy of their
behavioral reaction in the situation and may cause the train
driver to hold himself responsible for the accident.
Peritraumatic distress intensity was also
significantly positively correlated with the presence of
posttraumatic stress symptoms (r = 0.41, p = 0.01), with a
strong effect size (r = 0, 16). If the intensity of
peritraumatic emotional distress was reported to be high,
subsequent reported levels of PTSD symptoms were also
higher.
Results confirm our expectations regarding relevant
cognitive and emotional correlates of PTSD symptoms for
train drivers involved in PUT incidents.
4.3. Mediation analysis
According to current criteria for mediation
analysis (31), we checked if posttraumatic cognitions
satisfy necessary conditions as mediator of the
relationship between emotional peritraumatic reaction
and PTSD symptoms. The predictor needs to be associated
with both the mediator and the outcome variable and, after
controlling for the effects of the mediator, the relation
between predictor and outcome should reduce partially or
completely, accounting for partial mediation or total
mediation. Results showed that preconditions were
satisfied only for self-blame as the mediator variable,
because this was the only posttraumatic cognition that
significantly correlated to both outcome (PTSD
symptoms) and predictor (peritraumatic emotional
intensity). The diagram below shows results of the
mediational analysis we performed.
The recommended methodology (31) uses hierarchical
regression analysis to assess if the relationship between
peritraumatic emotional reaction(predictor) and PTSD
symptoms(outcome variable) modifies when controlling
for self-blame(mediator). All regression beta coefficients
were significant. Adding self-blame to the equation
significantly decreased the amount of variance in PTSD
symptoms explained by peritraumatic emotional intensity.
The Sobel test(32) used to test the indirect effect for this
mediation was found to be significant, 1,80 (p <0.03).
According to results, self-blame acts as a significant
partial mediator on the relationship between peritraumatic
80
Risk
Factor
No PTSD
Group
(N= 13)
M
S.D.
Incident
frequency
Self
cognitions
World
cognitions
Self-blame
5.53
2.22
17.92
1.32
11.23
4.67
8.46
3.71
Posttraumatic 37.61
Cognitions
5.97
Intensity of
11.61
peritraumatic 1.12
distress
Life threat
13.07
perception
8.62
Below
PTSD
threshold
Group
(N=100)
M
S.D.
Above
PTSD
threshold
Group
(N=16)
M
S.D.
4.29
2.51
23.23
5.81
13.45
8.46
8.50
4.21
45.18
9.84
11.73
2.63
3.93
2.59
30.40
10.97
17.00
4.83
15.56
5.66
63.00
17.00
15.06
3.21
1.70
0.18
14.36
0.00
5.53
0.00
18.32
0.00
24.35
0.00
11.50
0.00
12.46
6.83
16.56
9.33
2.14
0.12
Self posttraumatic
cognitions
World posttraumatic
cognitions
Self-blame
Global posttraumatic
cognitions
Peritraumatic
intensity of distress
T,
df, p
17.92
1.32
Significant
symptoms
group N=
16
30.40
10.97
11.23
4.67
17
4.83
- 3.24
27
p= 0.00
8.46
3.71
37.61
5.97
15.56
5.66
63
17
- 3.88
27
p= 0.00
- 5.56
19.35 p=0.00
11.61
1.12
15.26
3.21
-3.67,
27,
p=0.00
- 4.52
15.53 p= 0.00
81
Corina Doroga, Adriana Bban: Cognitive And Emotional Correlates Of Posttraumatic Stress Symptoms In Train Drivers
Exposed To Work Trauma
Table 3 Intercorrelations between risk factors and PTSD symptoms (N=129)
BravaisPearson
coef.
PTSD
symptoms
Intrusion
0.87**
Avoidance
0.93**
0.72**
0.83**
0.59**
0.68**
0.36**
0.24**
0.37**
0.35**
0.51**
0.40**
0.48**
0.48**
0.35**
0.45**
0.34**
0.43**
0.42**
0.22*
0.80**
0.27**
0.22*
0.24**
0.55**
0.31**
0.64**
0.23*
0.38**
0.30**
0.35**
0.36**
0.26**
0.71**
0.37**
0.28**
0.41**
0.42**
0.34**
0.35**
0.23*
0.25**
0.11
0.08
0.39**
Hyper
arousal
General
symptoms
Posttr.
cognitions
Self
cognitions
World
cognitions
9.Selfblame
10.Peritr.
reaction
M
10
15.61
4.82
7.20
3.80
18.51
46.62
23.58
13.66
9.37
12.13
SD
9.89
3.76
4.61
3.23
4.70
12.47
7.04
5.00
4.92
2.81
0.89
0.75
0.66
0.65
0.71
0.82
0.79
0.75
0.71
0.68
** p< 0,01
* p< 0,05
Fig. 1. Mediation diagram for peritraumatic emotional intensity as predictor of PTSD symptoms with self-blame as mediator
Self-blame
0.39**
Peritraumatic
emotional intensity
0,38**
0.41**
PTSD symptoms
0.31**
References :
1. American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders (revised 4th ed). Washington (DC): American
Psychiatric Association, 2000
2. Litz, B. T., Gray, M. J., Bryant, R., Adler, A. B. Early intervention for
trauma: Current status and future directions. Clin Psychol: Sci Pr 2002;
9: 112-134.
3. Brewin, C.R., Andrews, B., Valentine J.D. Meta-analysis of risk
factors for posttraumatic stress disorder in trauma-exposed adults. J
Consult Clin Psychol 2000; 68: 748766.
4. Ozer, E. J., Best, S. R., Lipsey, T. L., Weiss, D. S. Predictors of
posttraumatic stress disorder and symptoms in adults: A meta-analysis.
Psychol Bull 2003; 129: 5273.
5. Kallay, E. Trauma. From pathology to growth, ASCRED, ClujNapoca , 2011
6.Theorell T., Leymann H., Jodko M., Konarski K., Norbeck H.E.,
Eneroth P. "Person under train" incidents: medical consequences for
subway drivers. Psychosom Med 1992 ;54(4): 480-488
7.Cothereau C., De Beaurepaire C., Payan C., Cambou J.P., Rouillon F.,
Conso F. Professional and medical outcomes for French train drivers
after "person under train"accidents: three year follow up study. Occup
Environ Med 2004; 61(6): 488 494
8. Siol T., Schaefer A., Thomas W., Khle K. Posttraumatic Stress
Symptoms in Train Drivers Following Serious Accidents: A Pilot Study.
European Psychotherapy 2003;4(1): 3-9
9. Lunt, J., Hartley, R. Literature Review of Post Traumatic Stress
Disorder amongst Rail Workers 2004;
www.hse.gov.uk/research7hsl_pdf/2004/hsl0416.pdf
10. Yum B.S., Roh J.H., Ryu J.C., et al. Symptoms of PTSD according to
individual and work environment characteristics of Korean railroad
82
83
CLINICAL CASE
Rezumat
Prezentm cazul unei paciente de 39 de ani care a suferit
un transplant hepatic n 2011 la Institutul Clinic Fundeni
i care a dezvoltat agitaie psihomotorie, delir de
persecuie, halucinaii auditive i vizuale, anxietate
psihotic i insomnii la 3 zile de la transplant, fiind tratat
cu Olanzapin. Pacienta a fost admisa la unitatea de
primiri urgene a Spitalului Clinic de Psihiatrie Prof. Dr.
Alexandru Obregia n August 2014, pentru un al doilea
episod psihotic, la 6 luni dup ntreruperea tratamentului
cu olanzapin. Avnd dificulti n stabilirea unui
diagnostic de certitudine, am luat n considerare
numeroase diagnostice difereniale printre care i
deliriumul postoperator, psihoza indus de steroizi i
schizofrenia.
CONCLUZII: La fel ca i alti pacieni cu boli somatice
cronice, pacienii cu transplant de organ au un risc ridicat
de dezvoltare a simptomelor psihiatrice i a tulburrilor
psihice. Tulburrile de dispoziie i tulburrile anxioase
sunt cele mai frecvente afeciuni psihiatrice observate pre
i posttransplant, dei afectarea cognitiv i deliriumul
sunt cel mai frecvent ntlnite la scurt timp pre transplant
i n perioada preoperatorie datorit tulburrilor
metabolice i a efectelor interveniei chirurgicale. Psihoza
la pacienii cu transplant, dei rar, reprezint o
preocupare semnificativ datorit potenialului impact
asupra sntii i calitii vieii n cazurile n care nu este
bine manageriat. Complicaiile psihiatrice ale
transplantului hepatic se pot manifesta postoperator n
diverse moduri, ceea ce face diagnosticarea i tratamentul
o provocare. Avnd n vedere impactul pe care acestea l
au asupra pacientului i a prognosticului posttransplant,
subliniem importana ateniei, interveniei adecvate,
o p o r t u n e i c o l a b o r a re a m u l t i d i s c i p l i n a r .
Cuvinte cheie:
psihoz, transplant, complicaii
neuropsihiatrice.
MD, PhD, Clinical Hospital of Psychiatry Prof. Dr. Al. Obregia Bucharest, No.10 Berceni Street, email: anaanca@yahoo.com
Resident in Psychiatry, Clinical Hospital of Psychiatry Prof. Dr. Al. Obregia, Bucharest, email: dolfialexandra@gmail.com , naemhl@yahoo.com
Resident in Gastroenterology , Clinical Institute Fundeni, Bucharest, email: rosca.iulia@yahoo.com
84
Anca Talasman, Alexandra Dolfi, Mihaela Nae, Iulia Rosca: Diagnostic Challenges Of A Psychotic Disorder In A Patient
With Liver Transplant
recommendation of the gastroenterologist. The rest of the
treatment scheme (Neoral, Omeprazole, Medrol, Siluvit F,
Controloc) remained unchanged. The next day (19.08) the
hallucinations were still persistent, Haloperidol being
increased to 60 drops (6 mg/day).
Since 20.08.2014, the evolution of our patient started to
improve. She became critic regarding her hallucinations
and the psychotic anxiety diminished. The hallucinations
disappeared completely on 25.08.2014 after 12 days of
treatment with haloperidol (I feel better, I don't see or
hear anything strange), and the evolution was good until
discharge, on 27.08.2014 after 15 days of hospitalization
in the psychiatric unit. She was discharged with the
following treatment scheme: Haloperidol 60 drops (6
mg)/day, Lorazepam (2 mg/day for 3 days then 1 mg/day
for 7 days then only if needed), Romparkin 2 mg 3
tablets/day. At the recommendation of her surgeon, the
scheme was completed with: Medrol 20 mg 1 tablet/day,
Neoral (same scheme as during hospitalization),
Omeprazole 20 mg 2 tablets/day, Lactulose 3 doses/day
and Silivit F 1 tablet/day.
So far, the patient has been on the same treatment as after
August 2014 discharge, her evolution was very good,
without any psychiatric symptoms and she continued to
work as a nurse. She comes for check-up every 2 months.
DISCUSSION: In the described patient postoperative
delirium was likely after the first psychotic episode
because after surgery, delirium typically evolves
immediately after emergence from general anesthesia or,
after a lucid interval, in the first 72 hours [8]. This
diagnosis was eliminated after the second psychotic
episode, as the patient didn't suffer another surgical
intervention.
Another diagnosis we considered was psychotic episode
induced by corticosteroids or immunosuppressive agents.
Corticosteroids often induce psychiatric syndromes
including depression, mania, psychosis, and delirium,
known as steroid psychosis. Calcinurin inhibitors can
cause neurologic and psychiatric side effects. Mild
symptoms to severe complications can be found when the
normal range of dose is administered. At the first episode
this diagnosis could be possible because the psychotic
symptoms evolved within a short period of time (after 3
days) from the transplant when the patient was in
treatment with Solumedrol then with Tacrolimus which
are known for their possible psychiatric adverse events. At
the second episode the patient was in treatment with
Cyclosporine which is less possible to cause psychotic
symptoms. The most frequent psychiatric symptoms
second to Cyclosporine treatment are cited to be anxiety
and depression without psychotic symptoms.
[9,10,11,12,13]
Graft rejection was considered because of initial elevated
bilirubin, but was excluded according to the results of
investigations.
In chronic liver failure manifestations of encephalopathy
are common and may reach from mild obtundation with
dementia and movement disorders to deep coma [14]. In
the early phase of acute liver failure agitation, delusional
ideas, and hyperkinesias are also common until coma
finally ensues [15]. During the August 2014 admission the
patient presented tremor of the arms which resembled
flapping tremor. Lab tests were performed and the
diagnosis was excluded because of normal laboratory
86
findings.
Hepatic artery thrombosis is a devastating complication after orthotopic
liver transplantation often requiring revascularization or retransplantation. It is associated with considerably increased morbidity
and mortality. Acute cognitive dysfunction such as delirium or acute
psychosis may occur after major surgery and may be associated with the
advent of surgical complications [6, 16]. Abdominal ultrasonography
and CT excluded this diagnosis.
Disseminated intravascular coagulation was another diagnosis taken in
consideration because of the numerous ecchymoses on the arms, legs and
belly but it was excluded because the coagulation tests were all normal.
Intra-cranial tumors were excluded as a diagnosis because the cerebral
CT didn't reveal any pathological signs.
Schizophrenia was another discussed diagnosis because of her personal
and family history, but the evolution between the two episodes and after
the second one was good, so we also thought of a psychotic status after
liver transplant.
CONCLUSIONS: Similar to other populations with chronic physical
illnesses, patients with organ transplant are at elevated risk for
psychiatric symptoms and diagnosable psychiatric disorders. Mood and
anxiety-related disorders are the most common psychiatric illnesses
observed both pre- and post transplant, although acute cognitive
impairment and delirium are often seen shortly pre- transplant and
preoperatively due to metabolic perturbations and the effects of surgery.
Psychosis in transplant populations, although rare, is a significant
concern because of its potential impact on health and well-being if not
carefully managed [17]. Psychiatric complications of liver transplant can
manifest in different ways and at various time points which makes
detection and management challenging. Given the impact these have on
patient and transplant outcome, it stresses the importance of vigilance,
timely, adequate intervention and close collaboration between
disciplines.
REFERENCES:
1. Tombazzi CR, Waters B, Shokouh-Amiri MH, Vera SR, Riely CA.
Neuropsychiatric complications after liver transplantation: role of
immunosuppression and hepatitis C.
Digestive diseases and sciences. 2006 Jun; 51(6):1079-81.
2.Campagna F, Biancardi A, Cillo U, Gatta A, Amodio P. Neurocognitive
neurological
complications of liver transplantation: a review. Metabolic brain disease.
2010 Mar; 25(1):115-24.
3. Fukunishi I, Sugawara Y, Takayama T, Makuuchi M, Kawarasaki H,
Surman OS. Psychiatric disorders before and after living-related
transplantation. Psychosomatics. 2001 Jul -Aug; 42(4):337-43.
4. Stracciari A, Guarino M. Neuropsychiatric complications of liver
transplantation. Metabolic brain disease. 2001 Jun; 16(1-2):3-11.
5. Fukunishi I, Sugawara Y, Takayama T, Makuuchi M, Kawarasaki H,
Surman OS. Association between pretransplant psychological
assessments and posttransplant psychiatric disorders in living-related
transplantation. Psychosomatics. 2002 Jan-Feb;43(1):49-54.
6. Krahn LE, DiMartini A. Psychiatric and psychosocial aspects
of liver transplantation. Liver Transplantation, 2005; 10:
11571168.
7. Fukunishi I, Sugawara Y, Takayama T, Makuuchi M, Kawarasaki H,
Surman OS, Psychiatric Disorders Before and After Living-Related
Transplantation, Psychosomatics. 2001 Jul-Aug; 42(4):337-43.
8. Carmel Bitondo Dyer, MD; Carol M. Ashton, MD, MPH; Tom A.
Teasdale, MPH, Postoperative Delirium.A Review of 80 Primary
Data Collection Studies. Arch Intern Med. 1995; 155(5):461-465.
9. Sandeep Grover, Siddharth Sarkar. Journal of Clinical and
Experimental Hepatology. December 2012, vol2(4): 382-394.
10.Wada K, Yamada N, Sato T et al. Corticosteroid induced Psychotic
and Mood Disorders. Psychosomatics 2001; 42:461- 466.
11. Patten SB, Neutel I. Corticosteroid - induced adverse psychiatric
effects. Drug Safety 2000; 22:111-22.
12. Turjanski N, Lloyd G. Psychiatric side-effects of medications:
recent developments. Advances in Psychiatric Treatment (2005), vol. 11,
5870
13. Rojas- Estape H, Iclesias Rodriguez C, Murello LG. Hospitalized
psychoses after liver transplantation. European Psychiatry 2011
vol26:395
14. Riordan SM, Williams R: Treatment of hepatic encephalopathy. N
Engl J Med 1997, 337 (7): 473479.
15. Lee WM: Acute liver failure. N Engl J Med 1993; 329 (25):
18621872.
16. Goralczyk A, Meier V, Ramadori G, Obed A, Lorf T. Acute paranoid
psychosis as sole clinical presentation of hepatic artery thrombosis after
living donor liver transplantation. BMC Surgery 2010 10.1186/14712482-10-7
***
TGO (UI)
TGP (UI)
FAL
Bt (g/dl)
Bd (g/dl)
WBC(x103/ul)
NEU (%)
RBC(x106/ul)
Hb (g/dl)
HCT (%)
PLT(x103/ul)
aPTT
GGT UI
Albumin
(g/dl)
Total proteins
(g/dl)
30.07
Fundeni
Admittion
12.08
Fundeni
Discharge
41
63
124
6.2
11.0
78
4.2
10
32
208
-
70
111
343
3.3
11.7
76
4.0
10.3
32.3
207
-
13.08
Obregia 2nd
hospitalisation
day
69
169
497
2.4
1.57
8.45
81.9
4.12
10.9
33.5
210
21.3
416
-
14.08
15.08
16.08
17.08
18.08
19.08
20.08
22.08
26.08
Obregia
discharge
43
142
449
2.1
1.33
10.62
91
3.78
10
30.7
151
26
479
-
35
102
304
1.64
1.2
9.61
91
3.51
9.12
29.2
152
3.2
34
112
320
1.4
0.9
-
81
137
329
2.31
1.01
5.65
69.7
3.77
10.04
29.98
107
-
44
149
367
1.7
1.21
21.8
3.2
40
140
285
1.2
0.88
5.69
89.9
3.41
9
27.9
105
3.2
29
133
284
5.89
89
5.89
10.2
31.1
127
3.2
40
142
280
1.3
0.91
5.55
69.8
3.74
10.5
31.3
136
531.7
3.3
48
119
381
5.6
70
3.84
10.2
31.1
138
456
3.3
5.9
5.6
5.5
5.9
5.7
6.1
87
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Vrati R, Matei VMI. The crisis centre in Romania. Eur J Psychiat 2002; 29:305-311.
Reynolds CF, Frank E, Perel JM et al. Treatment of consecutive episodes of major depression in the elderly. Am J
Psychiat 1994; 151(12):1740-3.
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Vrasti R. The crisis centre in psychiatry. Toronto, London: Academic Press, 1993, 26-52.
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Schuckit MA. Alcohol-Related Disorders. In: Sadock BJ, Sadock VA, Ruiz P (eds). Comprehensive Textbook of
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90
91
ROMANIAN JOURNAL
OF PSYCHIATRY
CONTENTS
EDITOR-IN-CHIEF:
CO-EDITORS:
SPECIAL ARTICLES
& Personality Disorders Diagnostic Actualities
Aurel Niretean, Lukacs Emese, Tudor Niretean, Istvan Zsolt Szasz,
Adrian Horvath, Adina Mari
41
44
Dan PRELIPCEANU
Drago MARINESCU
Aurel NIRETEAN
ASSOCIATE EDITORS:
Doina COZMAN
Liana DEHELEAN
Marieta GABO GRECU
Maria LADEA
Cristinel TEFNESCU
Ctlina TUDOSE
REVIEW ARTICLES
& Negative Symptoms Of Schizopfrenia: From Kraepelin To DSM 5
Octavia O Cpn, Ioana V Micluia
48
51
& Clinical And Evolutional Aspects In Bipolar Disorder, Manic Episode (1) 56
Mdlina Vrabie, Victor Marinescu, Anca Talaman, Ioana Micluia
ORIGINAL ARTICLES
& Somatization Disorders In Children And Adolescents - A Local
Perspective From The Galati County
Marcela Cmpean, Carmen Truescu, Cristina Petrescu-Ghenea,
Alecsandra Irimie-Ana, Cristina G. Anghel, Liana Kobylinska, Iuliana
Dobrescu
63
88
APR
Romanian Journal of Psychiatry and Psychotherapy is indexed in the international data base Index
Copernicus Journal Master List, starting with 2009.
www.romjpsychiat.ro