COMITET DE REDACIE

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
ASOCIAIA ROMN
DE PSIHIATRIE I PSIHOTERAPIE
www.romjpsychiat.ro

REVISTA
ROMN
de
PSIHIATRIE

ROMANIAN JOURNAL OF PSYCHIATRY

Vol XVIII

Nr. 2

June 2016

QUARTERLY

CNCSIS B+

p-ISSN: 1454-7848

e-ISSN: 2068-7176

CUPRINS
ARTICOLE SPECIALE
& Depresia i suicidul la personajele feminine ale literaturii secolului XX

29

Ionu I. Jeican, Doina C.M. Cozman

ARTICOLE DE SINTEZ
& Persoana delirant ca actor ntr-un scenariu aberant

34

Mircea Lzrescu, Marinela Hurmuz

ARTICOLE ORIGINALE
& Delirul mistic i perspectiva realitilor multiple

39

Mircea Lzrescu, Jenica Blajovan, Marinela Hurmuz

& Tratamentul antipsihotic i funcionrea psiho-social n schizofrenie rezultate ale studiului

cohortei EUFEST din Romnia

45

Valentin P. Matei, Alexandra Mihailescu, Traian Purnichi, Ruxandra M. Al-Bataineh

& Depresia la tinerii aduli cu afeciuni somatice cronice - o analiz efectuat pe cohorta 1970 din
Marea Britanie

51

Alexandra I. Mihailescu, Valentin P. Matei, Liliana V. Diaconescu,

Ruxandra Al-Bataineh, Traian Purnichi

CAZ CLINIC
& Psihoza rezistent la un pacient cu comorbiditi - talasemie beta si toxoplasmoz latent

55

Alexandra Barbilian, Dan Prelipceanu

ISTORIA PSIHIATRIEI ROMNE

& Dosarul de securitate al psihiatrului Dan Arthur, o posibil docu-dram

59

Mihai Ardelean
INSTRUCIUNI PENTRU AUTORI

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

64

SPECIAL ARTICLES

DEPRESSION AND SUICIDE IN WOMEN

TH
CHARACTERS OF THE EARLY 20 CENTURY
Ionu I. Jeican1, Doina C.M. Cozman2
Abstract:
Literature is the art of words that describe life. In the case
of human life, suffering plays a special role, and literature
scrutinized man's suffering and described it in its various
forms.
This article presents three cases literary characters
whose psychopathology we interpreted on the basis of the

Even though women did not play a major role in

the political and social events of early 20th Century
Romania, they endured a lot of pain by them. We present
these sufferings as mirrored by the Romanian literature of
the time and interpret them from a medical point of view.
We analyzed the psychopathology of three
characters: Tincuta from the novel Tanase Scatiu by
Duiliu Zamfirescu, Ana from the novel Ion by Liviu
Rebreanu, and Margareta from the play Gaitele [Jays] by
Alexandru Kiritescu. From the literary text we collected
patient information and data for the mental state
examination, and based on the findings we established the
most probable diagnosis.
Tincuta a bridge between the landlord and
the steward
From an esthetic viewpoint, the work of Duiliu
Zamfirescu (1858-1922) is marked by classical orientation
(1) and classical balance (2). His most important
achievement is his contribution to the development of the
Romanian novel. Tanase Scatiu (1907) is the second
volume of the cycle Comanesteanu's Novel, the first serial
novel in Romanian literature (3).
His ideological development under the Junimea
trend guides Zamfirescu toward the social novel, the
conflict that opposes the old Romanian nobility (boyars
represented by Dinu Murgulet, a lover of the land and of
the peasants) to the new rural bourgeoisie (represented by
Tanase Scatiu, the prototype of the upstart steward, who
have nothing to do with tradition and land ties and whose
only purpose in life is to become rich by exploiting the
peasants; this social category will hold a considerable
influence in the late 19th Century Romanian political
scene) (3).
The action of the novel takes place in Walachia
(south of modern Romania). Tincuta, boyar Dinu
Murgulet's daughter, marries, at her parents' will, Tanase
Scatiu, and thus has to abandon her dream of love for
Mihai. She gets trapped in an unhappy marriage: From
the very first day [...] Tincuta's life was a constant fight
against misfortunes
Scatiu's character is outlined both by direct

literary text: Tincua from the novel Tnase Scatiu by

Duiliu Zamfirescu, Ana from the novel Ion by Liviu
Rebreanu and Margareta from the theater play
Gaitele [Jays] by Alexander Kiriescu.
Keywords: anxiety, depression, suicide, Zamfirescu,
Rebreanu, Kiritescu
description by the author (twisted nature, a miser and
a bragger, tyrant of the house) and indirectly by
dialogues or actions: (to the horse driver): Get off,
asshole [...] for the last twenty years you keep going but
never leave. If you could just go to hell!... [...], he whipped
the horses and took off leaving the coachman in the mud;
The master strikes like blind and the servant defends his
head with both hands
(to his daughter).
Zoita, my pet, stay here.
The girl is not too keen [...]
Don't want to stay with daddy? he asks putting
on a milder voice
No, she says, on the verge of tears.
Then just f* off [...] Go away! Out of my sight,
you grizzly chicken [...] Damned family breed!
As we can see, Scatiu has a despicable nature,
rude and vulgar, a man dominated by bouts of rage. He
offends and diminishes his wife: Aww! The stupid wife
I've got []. Tincuta casts him a glance. She's all
flushed with anger [], tears have come to her eyes.
You're all a bunch of nutters, you and him, and all your
kind [...]
You want to end my life before it's finished
Oh please, all of you are the devil's work, you
don't perish easily
Frustrated emotionally, hurt by the rift between
dream and reality, Tincuta lives in regret of her old love
dream for Mihai. During the years of the harsh and
humiliating existence with Scatiu, Tincuta develops a
depressive disorder, with elements of anxiety: Wherever
she turned her mind she saw only deep desolation: she
loathed her husband, she revolted against the society that
could tolerate him, against God who kept him alive; her
father had become selfish, childish, obsessed solely by his
land [] beside her, everything was painful and bleak
(depressive component)' : For some time already, I have
started to fear something unknown (anxiety
component).
Tincuta had had medical consultation and
received treatment, which she discontinued later: The
doctors believe I have a nerve disease [] They gave me

Student, Iuliu HaieganuUniversity of Medicine and Pharmacy, Cluj-Napoca

MD, PhD, Professor, Department of Clinical Psychology, Iuliu HaieganuUniversity of Medicine and Pharmacy, Cluj-Napoca
Corresponding author: Doina C.M. Cozman, MD, PhD, Professor, Department of Clinical Psychology, Iuliu HaieganuUniversity of Medicine and
Pharmacy, Cluj-Napoca, Str. Victor Babes, nr. 42, 400012, Cluj-Napoca, Romania, e-mail: doinacozman@gmail.com
Received March 4, 2016, Revised March 17, 2016, Accepted May 30, 2016
2

29

Ionu I. Jeican, Doina C.M. Cozman: Depression and Suicide In Women Characters of The Early 20th Century

me all kind of drugs, which made me sleep like a stone. I

gave them up. Under the circumstances, the character's
disease progresses toward major depression: The life
with her husband seemed a monstrosity, The smallest
anything made her cry, No one understood her, She
couldn't sleep and lost weight. She felt abandoned by the
whole world, drained of strength, without hope. The
constant conflict between the landlord and Scatiu
amplifies Tincuta's mental strain: Please father... What
can I do?... He chases me away, you chase me away... I am
so miserable!.

Figure 1. Tincua (Cristina Nuu) a screen shot from the

film after the novel Tnase Scatiu, directed by D. Pia,
1976
The depressive patient's perception of the world and life is
vividly depicted by the writer: She gave him the letter,
which he threw into the stove. They were both looking at
the burning paper, which crumpled and revealed the black
letters on the grey background. Tincuta nodded her head.
This is how all that is human perishes []
The idea of death had budded in her mind for a
while now. She felt sick and hoped to die soon.
From a psychological point of view, the events
are simplified, while from the point of view of the epic
construct they are hastened, precipitated (3). Tincuta
probably dies from conditions secondary to depression,
which are not described. Her tormented life dwindled
away slowly, little by little, leaving only the mark of the
very last moment of consciousness, that she stopped
hurting. She died with the clear thought of the happiness to
be no more.
In the end the narrator punishes the main
character. The peasants rise against Scatiu and after
getting justice from the state institutions they attack him
and kill him in a scene that forecasts the peasants' uprising
from the novel Rscoala [Uprise] by Liviu Rebreanu: In
one second they broke him to pieces [] At the inquest his
mashed brains were found mixed with pebbles, nails, a
torn kerchief that looked as if swept by the huge water
surge of the people's anger.
After the uprisings the peasants will be given
back their land.
Ana under the curse of dowry
A representative of the interwar period, Liviu
Rebreanu (1885-1944) is considered the father of the
Romanian modern novel. His novel Ion (1920), the first
and most powerful objective literary work in Romanian
30

literature (2), depicts the atmosphere of the Transylvanian

village in the beginning of the 20th century.
The novel architecture unfolds on two planes: the
peasants and the village intellectuals. The social layers
realistically reflect the social and economical conditions
of the times.
Ion of the Glaneta family, the main character, is
torn between two desires the voice of the land and the
voice of love. A stark poor lad, whom his parents gave
only his soul, seduces Ana, the daughter of the rich
peasant Vasile Baciu, making her pregnant in order to
force his future father-in-law to give him some land.
After the sexual intercourse with Ion, Ana
develops a feeling of anxiety: Since that night she had
been living in fear [...] Every minute she was waiting for
her sin to be revealed and this wait was even more painful
than the thought of the error itself.
When Ana can no longer hide her pregnant body
and Vasile Baciu finds out who the father is, he punishes
Ana by repeatedly beating her, which triggers in Ana
anxiety disturbances: The terror welled up in her so
fierce that she started crying in despair with a thin voice:
Don't kill me, dad, don't kill me, don't kill me! [...] and her
limp arms crossed over in defense over her round belly
[...] [Vasile Baciu] thrust his hand into her hair and with a
brutal wrench brought her down to the ground. Then he
began to punch her with his fists in the head, the ribs, the
belly, in a quick frenzy, panting and roaring: You slut!...
slut!... I'll kill you now!... Tramp!... Glanetu's son... is
that what you wanted? Here then, dirty whore! [...] His
eyes swollen with rage fell on the mocking belly and he
started kicking her with his feet, yelping with satisfaction,
as if every kick took a burden off his chest. Ana's crossed
arms tried instinctively to shield the fierce blows that
threatened the fruit of her sin [...] Vasile Baciu dragged
her inside, almost unconscious, closed the door and
continued the beating fervently. The next day Vasile
flung himself on Ana again, though she was covered in
bruises, and beat her till the neighbors rescued her from
his hands [...] From then on no day passed without beating
her until he got tired.
Sent by her father to discuss marriage
arrangements with Ion, Ana set off to Glanetau's house
with her heart heavy, her body mortified. Her mind was
drained like a dry sponge. No hope, no faith. She walked
without knowing, like a chased away dog. Her pace was
quickened only by the terror of the old man's strange gaze,
in which her death seemed to be floating [...] and found
herself in Glanetu's house without realizing whether she
had met anyone on her way or whether outside was
sunshine or rain [...]. The girl sat on the trunk uninvited,
as her knees were trembling like jelly. By this time the
character already suffers of depressive disturbance. The
etiology of this phase of depression includes the cruelty of
the father for his daughter. Ana, childish and candid, still
felt love for Ion: Ana could only think of him, forgetting
all shame, beatings and suffering, despite his
contemptuous attitude ( loathe Ana more than I would a
witch). Ana behaves like a victim fascinated by the prey
animal that caught her.
The wedding gives Ana the illusion of happiness
for a brief moment: she floats on a big happy cloud and
feels redeemed for all the pain. When during the dancing
Ion embraces Florica passionately, Ana feels that her

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

hopes of happiness are shattered and she falls back into
the same wretched life. Suddenly she starts crying bitterly
[...] Later on Ion sits beside her and says coldly: - Why
whimper now? You are not going to your death sentence.
Ion and his father in law are in a constant fight for
possessions; Ana is just a means, hateful for both. Because
Ana does not succeed in convincing her father to transfer
the assets to Ion, the latter begins to assault her physically
for the first time: with great lust he raised his hand and
hit her on the right cheek, then with the back of his hand on
the left [...] and hit her again over the eyes that looked at
him in fear [...]. You also want to crush me? You have no
pity either? Ion spits with relief and goes into the house.
At this moment the character's psychiatric condition
develops into major depression. Now she finally had to
admit that Ion hated her and all of a sudden she wondered
why she couldn't see it until then?. The lack of hope
throws a bridge between depression and the suicidal
tendency (4).
Under the stimulus of unbearable psychological
pain, Ana enters the realm of suicidal thinking (the
incubation phase of suicide, during which the individual
visits the idea of death and questions the need of dying, in
this case under psychopathological sociogenic factors (5):
Ion comes into the courtyard yelling [...] lashed forward
like a hawk and shouted [...] brandishing his knife: - Run,
tramp, go away before I send you to hell!... and stay away
from my house or I'll slice you to pieces! Thief [...] When
Vasile saw her approach [...] he shouted through his teeth
like a beast: - Don't come to me, you broad, or I'll break
every bone in you! You wanted a beggar, now stay with a
beggar... Look at him! Isn't he proud? Now you've learnt
your lesson [...] Where will I go now, she wondered, and
all the answers were gloomy [...], tempting her to put an
end to her misery, as life was no longer worthwhile [...]
That night for the first time she realized the abyss in which
her life was thrown and the thought of death came upon
her like a happy escape [...], like a tranquil shore where all
pain and hope had disappeared.

Figure 2. Ana (Ioana Crciunescu) screen shot from the

film Ion, after the novel with the same title, directed by
M. Murean, 1980
In the rural society of the time, the woman was no more
than a work hand, dowry and children bearer (6). While
she brings the food for her husband in the field, Ana goes
into labor and gives birth. Even at such moment Ion is full
of contempt: She knows fine well she's due and she comes
to lay in the field! Damn her stupid reckoning!
Ana's nervous tension continues to increase and
reaches a peak: The feeling of being useless in the world

follows her everywhere [...] She lived, but without any

hope, life had become a burden. The moment of self
destructive outburst, in which Ana embraces the idea of
committing suicide, follows shortly: When she closed her
eyes she always saw the water and a heavy hand was
pushing her towards it, like to a shore washed away of all
traces and regrets [...]
I shall kill myself, Ion
Yeah, damn well go and do that, this way I might
get rid of you!At this time the suicide victim
communicates her intentions, sends desperate signals,
trying in vain to communicate with Ion.
The characteristic features of major depression
are described once again by the author: She found no joy
in life. She felt her heart dry and empty, like a bag
thrown on the side of the road by an indifferent passer-by.
Little by little her mind switched off.
During the traumatization (the phase of putting
into practice the preconceived self destructive act (5)),
Ana commits a psychotic suicide by asphyxiation
(hanging): taking and unfolding it (the rope) in her hands,
she was full of joy [...] She rose on tiptoes, took the loop
with both hands and put her head through [...] She closed
her eyes and tried to let go of the rope [...] The rope
became tighter and tighter. There was no pain [...] She felt
a tickling and had to open her mouth and eyes. Suddenly it
crossed her mind that now she was going to die, she
panicked and wanted to reach the ground with her feet. But
she moved them in vain, her feet found no support. Then
she got frightened and started to choke. Her tongue
swelled and filled her mouth, so she had to put it out...
Then her whole body tingled. She felt an immense pleasure
[...] Her bulging eyes saw nothing. Only the tongue
continued to swell, defying and mocking, like a revenge for
the silence to which she had been condemned all her life.
The inner attitude of the suicide victim is
ambivalent till the last moment: she wants self destruction
and salvation at the same time (it crossed her mind that
that now she was going to die, she panicked and wanted to
reach the ground and escape death (4)
Not long after, Ion would die too, killed by
Florica's husband who discovered their love affair.
Margareta the tragic comedy
Alexandru Kiriescu (1888-1961) is one of the
most prominent playwrights from the period between the
two wars. Gaitele [Jays] (initially titled The Wasp
Nest), his main work, is a comic satire of the manners of
the bourgeoisie of Bucharest in the 1930s.
The action takes place in the rich family
originated from Oltenia, in Aneta Duduleanu's house, the
widow of the boyar Tasse Duduleanu. Aneta together with
her sisters, Zoia and Lena, are the jays, who pass
judgments on everyone around, but display a suburban
behaviour, playing cards and gossiping all day long, while
their favorite entertainment is to watch funeral
processions from the balcony (7). The play presents the
evolution of the conjugal relation between Margareta,
Aneta's youngest daughter, pregnant by the young
journalist Mircea Aldea. An orphan since the age of six and
very poor, Mircea accepts to be Margareta's kept husband.
MIRCEA: [] I really and truly believed that I escaped...
forever escaped the dejection in which I was rolling till
then...
31

Ionu I. Jeican, Doina C.M. Cozman: Depression and Suicide In Women Characters of The Early 20th Century

Initially Mircea represents for Margareta the

ideal in life freed of the coarseness of her family.
Pervaded by the comic language, the play is an
outflow of wickedness, with constant irritation and
interruption of the dialogue partner; thus a permanent
tension is built, scattered with outbursts: at some point or
other every character shouts, yells, jumps,
jerks, or is in the thralls of a terrible fury
MIRCEA: [about Margareta] She has complained of
dizziness for four days... sometimes nausea... [] No
longer than today she threw up []
ZOIA [jumps]: Oh, she's got that... meningitis.
WANDA: Meningitis is in the brain, auntie
ZOIA: [] I meant the other... appendicitis... get her
operated. (to Margareta). Don't be afraid of the knife, pet,
otherwise the pus will break your bowels and you die
within 24 hours [] I am more of a doctor than any doctor.
I buried three children and also mummy and daddy...
Margareta's drama slowly builds up. With a
behavior detached from the typical Duduleni's rudeness,
she is held in contempt by her family.
ANETA (to Margareta):... Oh dear, how stupid you are!
Who you take after I couldn't tell, as I was very smart []
Just look in the mirror and see what a face you got []
MARGARETA: She's not my mother, she's my enemy [] I
can't stand her
As a constant laughing stock of the jays, she
considers Mircea her only moral support:
[LENA (to Margareta): Wait and see: it was like a big
black water... You were on the shore with Angelica [],
you know ... the one who died in childbirth [] and the
water was rising and coming and roaring... You wanted to
jump in, but kind of shy. Then she grabbed you by the
shoulders...
ANETA: Who did, sis?
LENA: Angelica, sis... and she pushed you into the
stream...
ANETA: But Angelica didn't die in childbirth.
LENA: Then how did she die?
ANETA: Of peritonitis
LENA (adamant); That's childbirth! D'you think that
Dumitrescu's niece, Anuta, died of something else?
ANETA: That one died of cancer. Cancer ate into her chest
till it got to her heart [...]
LENA (determined): Childbirth I say. Her breasts fevered
with milk and gone to cancer. []
ANETA (to the other wailing two): Ho now, shrews, you'll
have enough time to weep her!... MARGARETA (who had
listened in total silence, suddenly started to cry in a
terrible panic that seized her entire body): Mircea!...
Mircea!... Mircea!...
Margareta expresses her despair regarding the
atmosphere in her mother's house: MARGARETA
(bursting out): [...] I'm sick of it...! I can't stand it
anymore... I'll kill myself
Margareta suffers from a depressive disorder,
caused by the continuous contempt and mockery from her
family. The only thing that obstructs the depression to
progress is her love for Mircea: MARGARETA (simply):
He is the only love I have in this world. However, Mircea
is seduced by Wanda Serafim, a woman of doubtful morals
arrived from Paris, a niece of Tasse Duduleanu, to whom
he confesses the lack of any feelings for Margareta.
32

MIRCEA: She removed all emotion from her existence,

there is such a void around her heart that nothing vibrates
anymore, there is no life, nor feeling, except...
WANDA: You!...
MIRCEA (oblivious): Me.
WANDA: Horrible creature
When she sees the coldness and lack of feeling in
her husband's behavior, Margareta undergoes the
transition toward major depression:
MARGARETA (clinging to him in despair): Mircea, you
don't love me anymore!... You run away from me!... You've
become a stranger [...] (between sobs): [...] I am so
miserable... So miserable [...] Don't you think it's odd that
I, the naive one whom my family, my friends consider
stupid suddenly understand so many things?
MIRCEA: I admit! [...] You drove me insane with your
phantasies, your insinuations! [...] (he shouts) You must
stop, stop it now! [...]
MIRCEA (roars into her face): Beast... You are truly one
with your beastly family! [...]
MARGARETA: Aren't I? Aren't I just?
MIRCEA: You are!... You may say that over and over, like
an idiot!... [...] Monster!... Murderer!... [...]
MARGARETA (with tears in her eyes): Whatever you say,
my love... [...]
MIRCEA (turning his head, through his teeth): Hysterical
woman...

Figure 3. Margareta (Maria Ploae) screen shot from the

film, directed by H. Popescu, 1987
The moment of the self destructive outburst is when, due
to the family indiscretions, Margareta finds out that
Mircea has a love affair with Wanda. Traumatization
follows shortly, Margareta commits suicide by a chemical
method (overdose of opium infusion):
ANETA (showing a pack of letters): Here! [...] Letters
from your husband to Wanda. He writes her three a day...
[...]
IANACHE: Love letters.
MARGARETA (sustaining the blow): what.. what...
GEORGES (brutally): Mircea cheats on you with
Wanda... Mircea is Wanda's lover.
MARGARETA (deadly calm): It's not true. [...]
(During this time Margareta drops her head on the back of
the armchair and waits. Georges reads). I have barely
left your arms and I already tremble with the desire to see
you again. What poison have you dripped into my blood,
Wanda? (He stops)
MARGARETA (breathless): Read on... [...]
GEORGES (reading): I got home, I entered our room
[...] Margareta slumped in her recliner she doesn't seem to

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

leave at all now, gave me a dead smile. There was an awful
smell of ether and bromide around her... Wanda, Wanda, if
there wasn't for your love to... (he stops) [...]
ANETA (impatient): Why do you stumble all the time?
Can't you see the girl wants to know everything?
GEORGES (upset):Wait, I can't make out the writing, it's
all scrawled...
IANACHE (sarcastically): His hand was shaking... he was
excited... [...]
GEORGES [...]... ...to support me, to give me strength
[...], I would empty the bottle of laudanum I see on the
medicine table, the drink of oblivion and of
nothingness...
MARGARETA (simply): Read... (She goes to the medicine
table and pours a full glass from a red labeled bottle, while
Georges reads on [...] All of a sudden Margareta drops the
glass she was holding, which breaks with a noise. She falls
on the floor. Georges, with a strangled voice) Margot!...
ANETA (cries): What did she drink ? What did she drink ?
[...] The bottle with the red label... What did she drink?
IANACHE (rushes to the table, takes the bottle and reads):
Laudanum.
Margareta's suicide distresses Mircea emotionally and he
refuses to continue his relationship with Wanda.
In lieu of conclusions
All three characters come from well-off families,
and in the etiology of their psychopathology we find social
factors the struggle for wealth of the people around
them. While Tincuta marries somewhat forcibly, Ana and
Margareta love their husbands and the revelation of
unreciprocated feelings is an emotional shock.
Starting from her husband's humiliating
behavior and the constant conflict between husband and
father, Tincuta initially develops an anxious-depressive
disturbance that progresses into major depression; she
succumbs most probably to secondary conditions.
Tincuta's psychopathology is relatively briefly presented,
in a simple, swift manner. From a medical point of view
some of the stages of the disease evolution are omitted,
while the precise cause of death is left out; one may guess,
however, that certain conditions secondary to major

depression indirectly led to her death.

Ana's psychopathology emerges under her father
and husband's physical and verbal aggressions, together
with the contempt of the people around her. Initially she
develops an anxiety disturbance, which quickly shifts to
anxious-depressive disorder and ends in major depression
and suicide. The onset and evolution are presented
accurately and in detail from a medical point of view.
Given the literary genre of the work of origin,
Margareta's case is presented with relative accuracy from
a medical viewpoint. Her psychopathology could have
also been worsened by dysgravidia. Held in contempt by
her family, rejected and betrayed by her husband,
Margareta undergoes the stages of depressive disorder to
suicide.
Aknowledgements
The authors had and equal contribution and approved
the final version of this article.
Disclosure
No potential confict of interest to disclose.
REFERENCES
1. Petrescu I. Duiliu Zamfirescu. In: Zaciu M (ed). Scriitori romni.
Bucureti: Editura tiinific i Enciclopedic, 1978: 487-491.
2. Lovinescu E. Critice Vol II. Bucureti: Editura Minerva, 1979: 80, 170.
3. Sndulescu A. Duiliu Zamfirescu. In: Cioculescu , Papadima O, Piru
A, tefnescu C. Istoria Literaturii Romne epoca marilor clasici,
Bucureti: Editura Academiei Republicii Socialiste Romnia, 1973: 663698.
4. Cosman D. Sinuciderea, studiu n perspectiv biopsihosocial. ClujNapoca: Editura Risoprint; 2000: 39-42: 159.
5. Cosman D. Psihologie medical. Iai: Editura Polirom; 2010: 401-402.
6. Calinescu G. Istoria Literaturii Romne. Bucureti: Editura Minerva;
1982: 732.
7. Crohmlniceanu Ov S. Literatura romn ntre cele dou rzboaie
mondiale Vol III Dramaturgia i critica literar. Bucureti: Editura
Minerva, 1975: 54-57.
8. Zamfirescu D. Tnase Scatiu. Bucureti: Editura Eminescu, 1985.
9. Rebreanu L. Ion. Bucureti: Editura Liviu Rebreanu, 2008.
10. Kiriescu A. Gaiele i alte piese. Bucureti: Editura Eminescu, 1986,
191-271.

***

33

REVIEW ARTICLES

THE DELUDED PERSON AS AN ACTOR IN AN

ABERRANT SCENARIO
Mircea Lzrescu1, Marinela Hurmuz2
Abstract:
The paper develops the idea of interpreting delusion based
on Gallagher's multiple realities perspective. The self is
considered to be permanently involved in different
scenarios, including fictional ones, such as watching a
play or reading a novel. The narrative theories of
personality also discuss the involvement of the self in
various scenarios, but with the possibility of returning to
its basic, biographical identity. Delusion is interpreted as
a fall in a role of an aberrant scenario, which the subject

cannot escape from. The multiple realities are discussed

from Mircea Eliade's perspective regarding the sacral time
of the myth that forms the background for the time and
structure of the fictional narratives. The normal psyche is
characterized by a meta-representational structure, which
allows the self to play the roles in different life scenarios.
Delusion is interpreted as the alteration of the autonoetic
consciousness and of the mental time travel structure.
Key words: delusion, fictional realities, self, mental time

INTRODUCTION

highlight four problems which make the study of delusion

difficult.
The first difficulty lies in the fact that delusion is
part of multiple clinical contexts. We consider that, from a
psychopathological perspective, the delusion which
characterizes the Persistent delusional disorder in ICD
10 (F22) (WHO 1992) is more relevant to our purpose
than the schizophrenic delusion.
A second aspect concerns the frequent
correlation between delusion and different perceptive
disorders, such as the salience phenomenon, illusions,
hallucinations, derealization, sensitivity, centrality,
reference. These inferences draw attention to the fact that
the psychic structure disturbed in delusion is a transsituational one, implying a meta-representational level.
The third problem implies the various notions
used to characterize delusion, in different domains. We
can mention some of them: belief, truth, evidence, doubt,
certainty, idea, experience, argument, proof, faith,
conviction. These terms are also used in philosophy. The
ancient skeptics talked about doubt and so did
Descartes. The concept of idea was mentioned by
Platon, later by Kant and it currently has different
meanings.
The fourth difficulty is related to the classical
problem of the primary delusion. In his main article in
1910, Jaspers made a difference between the abnormal,
but comprehensible prevalent process and the
incomprehensible primary delusion (Jaspers, 1963). The
primary delusion emerges in a different way, being
preceded by a delusional mood. The subject feels that
everything around him has a special, mysterious
significance related to him (the feeling of centrality). At
a certain moment, a common perception receives a special
meaning and clarifies the delusional, incomprehensible
theme (delusional perception). It is the moment when the
psychopathological process takes place and moves
the subject on the incomprehensible orbit of the primary
delusion.
However, the clinical experience proves that a

Delusion is still defined by reference to Japers

(1997), who considered it an abnormal, incomprehensible
belief in a false idea, which takes place through a
psychopathological process. In a manual of descriptive
psychopathology, it is stated that:
For Jaspers, the characteristics of delusions are
that: (a) they are false judgements, (b) they are held with
extraordinary conviction and incomparable subjective
certainty, (c) they are impervious to other experiences and
to compelling counterargument and (d) their content is
impossible (Oyebode 2008, 122).
During the last decades, there has been an
increasing number of psychopathological studies
regarding delusion, especially due to the development of
cognitivism. The top-down and bottom-up theories
consider delusion a false belief (Bertolotti 2010). Lately,
this thesis was frequently argued (Stephens 2009).
Recently, Gallagher (2009) suggested another approach of
delusion, from the perspective of multiple realities
(MR). He stated that the person is living in various realities
in his everyday life, for example when going to the theatre,
when reading a novel or when playing a video game. These
realities are different from the practical reality of the
everyday life. So is delusion, which absorbs the subject in a
particular reality. Still, when living in the multiple
realities, the normal subject is able to return to his normal
life.
We will try to develop Gallagher's hypothesis
starting from the perspective of the narrative psychology
of the person, referring to the special temporal dimension
of the narrative reality and considering the particular
domain of the sacral myth. For this purpose, we will
discuss Mircea Eliade's interpretation of the special
temporality of the myth and of cultural narrativity.
DIFFICULTIES IN THE STUDY OF
DELUSION
Before presenting our own thesis, we will shortly
1

MD, PhD, Prof Dr, Eduard Pamfil Dept. Of Psychiatry, Univ. of Medicine Timisoara, I. Vacarescu Str. 21, mlazarescu_39@yahoo.com
MD, a 3rd year resident in psychiatry, Eduard Pamfil Dept. Of Psychiatry, Univ. of Medicine Timisoara, Psychiatric Clinic Timisoara.
Received October 29, 2015, Revised November 20, 2015, Accepted December 4, 2015
2

34

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

progressive variant of the emergence of delusion is also
possible, even in the case of the delusion of jealousy. For
example (a personal case):
A 35 years old man progressively gets to the
conclusion that his wife is cheating on him with her boss,
with all her colleagues and, later, with all the members of
the administrative community of the town. For this reason,
they move to a different city. There, the history repeats
itself. The situation becomes unbearable, because people
start to laugh at him on the street. After moving to another
place, having the same problems, the man accepts the
admission in a psychiatric unit, 4 years after the onset.
The delusional jealousy and the transition from
normal jealousy to prevalent and delusional ideas have
been studied by many authors (Shepherd 1990, Enoch
1991). All of them agreed that a progressive evolution
towards delusion can characterize jealousy; and also
dysmorphophobia, hypochondria or the ideas of
reference, as classically described by Kretschmer (1974).
Two decades ago, Hollander (1993) suggested a possible
obsessive-compulsive spectrum and imagined a
continuum between the pole of obsessive uncertainty and
the one of delusional certainty, passing through the overevaluated ideas; the anxious-phobic phase could be placed
at the beginning of this continuum (Fig.1).

Although we agree with the idea of the

continuum, we also need to accept the idea of a
disruption or fall on another orbit in the case of
delusion (Fig.2).

The slowly progressive emergence of delusion

and the sudden occurrence of the primary delusion are
complementary. The last one is important for
understanding delusion, because it highlights the
existence of a psychotic level. This level can be considered
similar, but specifically different, from the psychotic level
of mania, major depression, depersonalization,
disorganization, catatonia, obsessionality etc. The
question would be: what is the psychic structure centered
by the self which is impaired in this case of psychosis' in
general and in the case of delusion in particular?
PERSONAL THESIS
Our own thesis states that delusion can be
characterized by an abnormal identification of the subject
with a special role in a narrative scenario, a real or a
fictional one. This scenario refers to the subject's identity,
including: his state of being, his value, relationships,
situation or his own self. For example: the role of a sick,
dysmorphophobic, spied, persecuted, over-capable,
guilty, incapable person, the role of someone who has a
special mission given by God etc. The presence of a
narrative scenario leads us to the multiple realities
described by Gallagher.
From a phenomenological-existentialist
perspective, the deluded person can be compared to an
actor playing the role of King Lear or Othello. In the same
way, an obsessive person is similar to someone who is
permanently preoccupied with the construction and
cleaning of a house and a manic person with someone who
takes part in a New Year's Eve carnival. The obsessive
person becomes deluded only if he enters the role of a
person who is in great danger of contamination or who is
guilty for a possible danger produced by his magical
thinking. Similarly, the manic person becomes deluded
only if he takes the role of a character who is solving the
world crisis or who has the mission of saving humanity;
thus, who is transposing himself into a narrative scenario.
Our thesis highlights that the idea lying in the
center of the delusional belief is characterized by an
identitary role in a narrative scenario. This approach leads
to Tomkins' narrative psychology. Tomkins, cited by
McAdams (2008), suggests that the person is continuously
generating dramatic scenarios for the problematic
situations of his everyday life. He is the author and the
actor in these scenarios. In normality, he is permanently
part of various scenarios with different durations. He can
evaluate their importance and can get out of them
whenever he wants to. But he is constantly maintaining his
biographical self identity, his agency and the ownership of
his creativity regarding the events in which he is involved.
Narrativity is both implicit and explicit. Personal
narrativity implies the use of language and expresses itself
through different imaginary scenarios, dialogues with
oneself, biographic reports, potential or real narrations of
situations and events. All these can be narrated in different
ways and moments by other people or by the subject, as
memories. They can be studied systematically, as
McAdams' narrative psychology did, for example. By
playing different roles in multiple narrative scenarios, the
subject is living on various levels with different objectives
and different durations. This aspect is related to the study
of the mental time travelling function, in relation to
Tulving's autonoetic consciousness (1983). The subject
35

Mircea Lzrescu, Marinela Hurmuz: The Deluded Person As An Actor In An Aberrant Scenario

expresses himself through a variety of selves, on the

background of a basic biographical identity and time.
Hermans has also studied this aspect (2009), based on
James' ideas of the multiplicity of selves (1996).
In the case of delusion, a certain scenario
becomes dominant. The subject collapses in a specific
role, which merges with his own identity. The person's
receptivity and creativity for the involvement in other
scenarios decrease. The aberrant scenario is lived by the
subject in relation to the real world or to a fictional one.
E.g.:
A patient shoots another person believing them
to be an enemy assassin and himself to be the Queen's
personal bodyguard. (Oyebode 2008, 122).
A manic patient claimed to be Mary, the Queen
of Scots. She accepted that the queen in question lived and
died centuries ago but claimed descent from her and felt
fully entitled to say that she was she (Oyebode 2008,
126).
A patient explains that everyone smiles and
nods when they see me because I have been sent by God to
communicate with people about evil and I have a letter
from the Pope as proof. (Oyebode 2008, 134).
Understanding the delusional idea as the
placement of the subject in an aberrant identitaryrelational role in a narrative scenario is consistent with
Gallagher's point of view. He interprets delusion from the
perspective of multiple realities (MR). Gallagher (2009)
goes further with Shultz's interpretation of James' concept
of sub-universes and discusses the realities which are
different from the everyday life: the reality lived when
going to the theatre, to the cinema or when playing a video
game. The subject can temporarily enter the role of the
characters of these realities and can take part of their
adventures. Similarly, in his dreams, he becomes the hero
of some particular events. Still, in normality, the subject is
in permanent contact with the everyday events and he can
always return to his real life after spending time in the
fictional or virtual reality.
We believe that Gallagher's idea deserves to be
analyzed and developed. It implies the evaluation of the
identitary roles from the aberrant scenarios of the
delusional sub-universes and an analysis of these multiple
worlds. It highlights the psychological characteristics of
the person living in the realities of the theatre plays,
novels, stories, myths or games. In relation to these
realities, we can better understand the subject's fall in
the abnormal situation of being in the world, in a parallel
reality than the one of everyday life; a reality which
absorbs him and which he cannot abandon on his own.
THE PROBLEM OF THE MULTIPLE
REALITIES
The deluded person falls in a special world, parallel to
the many worlds which form the socio-cultural realities
(SCR). When analyzing delusion, psychopathology needs
to take into account not only the impairment of the
psychological processes (perception, cognition, ideation,
memory, representation, imagination, will, motivation,
expectancy, evaluation, belief etc), but also the realities of
the multiple human worlds, formed by novels, theatre,
history, myths, in which the person lives during his life.
The SCR become part of the individuals through the
36

process of education.
The subject has at his disposal the multiple
realities (MR) and he is permanently connected to them
in his everyday life. He can enter these realities if he needs
or if he wants to (Table 1).
Table 1. The main realities connected to the SCR
a)
dreams;
b)
the religious and mythic reality, when participating to
the sacral rituals of prayer or other religious practices;
c)
going to theatre plays or movies; it also includes the
reality of an actor who is performing in a play and who is
transposed into a fictional reality. A special case is the one of
the writer of a play, who is directing and then playing a role in
it;
d)
the reality of video games;
e)
the reality of different feasts, such as carnivals;
f)
reading a novel or listening to stories; this category
also includes the special case of the novel writer, who gives
life to special characters and situations;
g)
listening to or participating in everyday narrative
histories regarding known or unknown persons;
h)
the artistic creativity, for example poetry or painting,
but also the scientific, theoretic creativity;
i)
creativity in the domain of mathematics and
philosophy;
j)
the trance and mystic - ecstatic states; visions;
k)
the delusional reality.

The most important themes related to delusion

are the c),d),e),f),g) and partially a) situation. The b) and c)
situations are related to mania. The h),i).j) situations are
especially important for schizophrenia. The a) situation is
met in delirium and may have some correlations with
delusion.
Some of these more or less fictional realities are
common for everybody. However, there is no operational
definition for the normality of the persons who are
involved in these realities. The normal person takes part in
these realities with his whole cognitive and imaginative
functions, in a special existential temporality, during his
entire life.
The discussion of the dream in this context is important for
highlighting the personal and subjective character of the
states we describe in our thesis. All these realities involve
the subjective world of the person. Dreams are present
in a different reality than the one of the physical and biopsycho-cultural human world. However, they derive from
the everyday life. This aspect reveals the fact that, in all the
sub-universes of the SCR, the subject partially detaches
from the environment and his availability for connecting
to the world is temporarily limited. When watching a play
or while reading a book, the subject does not think about
something else. He is isolated, but, in the same time, he
remains connected to the SCR. This connection is also
present in the case of creativity (h) and i) situations).
The subject is involved in different scenarios and
roles not only by entering the multiple realities which are
parallel to the SCR. He is also playing these roles inside
the SCR, during his everyday life.
The sociology of the 20th century has developed
the concepts of social status and social role. These
concepts apply to the family institution as well. The
person can have different statuses: engaged, married,
divorced, widowed etc. and, in the same time, he has

Romanian Journal of Psychiatry, vol. XVIII, No., 2016

different roles: the role of a parent, child, relative etc.
Another perspective of the individual roles considers the
dramatic process of human existence. People fall in
love, they get married, they argue. Children are planned,
born, they grow up, they have their own families, they
build a house etc. The old person retires, has a will, and
leaves behind a material and spiritual heritage. All these
processes and events are in a continuous development, but
they can also be narrated as part of the personal biography.
The events which happen in real life are similar to the ones
happening in a play or a novel. For example, a husband can
be jealous in the real life, but also in a tragedy. The
exaggerated preoccupation for illness, erotomania,
persecution or the will for harming someone are realities
of the SCR, but can also be present in the fictional
narrative realities of the movies or novels. Everyone is
permanently playing the social roles of the cultural society
he lives in. But these scenarios are part of the subject only
to a certain level of his psychic structure. From the level of
social roles, the subject can slip to the delusional subuniverses.
If we consider the MR concept and the delusion
viewed as an aberrant involvement of the subject in a
certain sub-universe, we need to ask ourselves: what is
the basal ontological structure of these human subuniverses or sub-realities? For understanding these
realities, we suggest a model based on the special narrative
temporality of the sacral and profane worlds, described by
Mircea Eliade. The narrative time of the myth which
evokes the origins of the world is different than the
narrative time of the profane actions. The sub-universe of
the human practices, as well as the one of the novels, could
be explained from this perspective.
In his classical books Treaties on the history of
religions (1987) and The myth of the eternal return
(1971), Eliade analyzes the fact that the whole human
history has been structured by the polarity between the
sacred and the profane. In every culture (until the end of
modern era), there has been the belief that the unnatural
forces had created the world in the holly time of
beginnings. The sacral practices, the rituals and religious
ceremonies are an important part of human existence.
People use the sacral rituals in order to invoke the time of
beginnings. They tell the mythic stories in a special place
and time. In the same way, the legends and histories of a
community draw the people out of the time and space of
the everyday preoccupations. By listening to these stories,
they ignore the reality of the present time and they are
placed in a different time, the one of the once upon a
time narrations. Besides the present reality of the
environmental world, people also live in the temporality
of other narrative realities. The paradigm of these
temporalities is the originary time of creation. Eliade
believes that this model can also be applied to the special
reality of literature.
In his book Aspects of myth (1963), published
in the USA, Eliade discusses the fact that people need the
stories and they need to enter the foreign universes
created by stories. It is part of the human condition. Every
person is fascinated by different narrations, by the stories
of historic or literary characters. Reading a novel or a
history implies the exit from the time of the everyday life.
A comparison can be made to the traditional societies'
practices of reciting a myth. In both situations, the person
is getting out of the personal and historical time and he is

entering a fabulous, trans-historical time. The reader is

placed in a foreign, imaginary time. Thus, the novel has
access to the primary time of the myths.
The immersion in a delusional state and in a
fictional delusional scenario can be compared to the
normal, periodical entering of any person in the narrative
time of a novel or a religious ceremony. Each person is
living in the multiple realities that have their own
specific time. The difference is that the deluded person is
falling and is locked in his fictional, absurd scenario.
The patient acts according to the rules of this particular
reality and he is not able to get out if it. The delusional
world is simplified, rigid, inflexible and the complex
temporal structure of the person is blocked. The identitary
self is the main structure which is impaired in the
delusional pathology. The deluded person over-identifies
himself with his aberrant role. On the contrary, in the case
of the shizo-hebephrenic disorder of the self, described by
Minkovski (1927) and Parnas (2011), this thing is not
possible any more. That is why the schizophrenic delusion
is bizarre and depersonalizant.
This interpretation of delusion implies the
problem of narrativity and human language. Thus, it is
correlated with Crow's approach of psychosis, who
considers that schizophrenia is a price paid by evolution
for the development of language, 150000 years ago.
D E L U S I O N A N D T H E M E TA REPRESENTATIONAL LEVEL
We cannot describe the correlation between
delusion, narrativity and temporality without considering
the psychological structure where this process develops.
. It needs to be a representational and metacognitive structure, which is connected to the narrative
biographic identity and also with the situational
experiences of the person, which have different temporal
durations. This meta-representational structure is
connected to the narrativity of the multiple realities we
have described. The subject is permanently evaluating the
situations in a meta-cognitive way. He is imagining
problem-solving scenarios, based on probabilistic models.
These scenarios also refer to his long-term relationships,
to identitary and self-evaluation aspects. Besides the
present situation, the self is also part of various projects of
different durations. Tulving's model of the Mental Time
Travel can be mentioned here.
We suggest the following model of the self as a
whole (Fig. 3).

37

Mircea Lzrescu, Marinela Hurmuz: The Deluded Person As An Actor In An Aberrant Scenario

In delusion, the meta-representational structure

of the psyche involves the subject in the role of a hero in
different scenarios which takes him out of the context. The
meta-representational structure can also be involved, in a
different way, in the mood and obsessive-compulsive
disorders (Fig. 4).

In the schizophrenic delusion, the subject is

depersonalized, so that the hero in the delusional scenario
becomes an abstract entity, almost completely absorbed in
fiction. Schizophrenia is based on the pathology of the
minimal, nuclear self and not the one of the biographic,
narrative self which places the subject in different social
roles. Through the collapse of the intimate-public
relational structure, the self loses his autonomy. This
aspect is expressed by Schneider's first rank symptoms.
That is the reason why the schizophrenic delusion is only
one special, atypical form of the delusional pathology.
From this perspective, the primary delusion discussed
by the psychopathologists in the last decade might not be
the ideal model for the study of the delusional pathology.
CONCLUSIONS
The interpretation of delusion as the fall of the
person in a role of an aberrant, rigid and fictional scenario,
from the perspective of multiple realities, represents an
idea which deserves to be debated and studied in the
future.

38

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***

ORIGINAL ARTICLES

THE RELIGIOUS DELUSION AND THE MULTIPLE

REALITIES PERSPECTIVE
Mircea Lzrescu1, Jenica Blajovan2, Marinela Hurmuz3
Abstract
The religious delusion has not been the focus of many
clinical and psychopathological studies. A possible reason
could be that it cannot be easily assessed through the
cognitivist research methodologies. An interesting
approach is the one of the multiple realities (the
fictional realities of literature, theatre, virtual computer
world etc.), an idea recently developed by Gallagher. The
cases of religious delusion are characterized by a
psychopathologic process of depersonalization/transpersonalisation, by entering a particular role in a special

mystical world; a simplified and distorted one. The paper

discusses 12 cases of religious delusion from the Case
Register for Psychosis Timisoara. It focuses on the role of
narrativity and the process of identification with
characters from the mythical narrations in delusion. It
suggests the development of phenomenologicalexistentialist research in the domain of delusion from the
multiple realities perspective.
Key words: delusion, religious delusion, multiple
realities, psychopathology

Delusion and the hypothesis of the multiple realities.

Jasper's classical definition of delusion (1)
considers it a judgement (idea, thought, theme) held with
an extraordinary conviction, with an incomparable
subjective certainty, which is impervious to other
experiences or to compelling counter-arguments and
which has an impossible content.
Understanding delusion as an abnormal belief is
maintaining this problem in the field of cognitive
disorders, as it used to be in the 19th century (2). The
recently growing interest of cognitivist psychopathology
in understanding delusion as an abnormal belief led to the
development of partially validated theories, such as the
bottom-up, top-down or the deficit in abandoning a
false idea models (3,4). The interpretation of delusion as a
false belief was challenged by several arguments (5,6).
A recent approach, developed by Gallagher (7),
suggests the interpretation of delusion from the
perspective of multiple realities (MR). This idea is based
on the fact that a person is not only living in the physical
reality, but also in other more or less fictional realities,
which are part of his everyday life and which he can access
for short periods of time. For example: watching a theatre
play, reading a novel, playing a computer game. The
scenarios of the fictional realities are characterized by a
different spatial, temporal and causal structure than the
daily events. When entering these realities, the subject
partially extracts himself from the everyday situations and
becomes part of different events, being able to identify
himself with the fictional heroes of those worlds. Later, he
is able to re-engage in his current life. Gallagher writes:
Besides the world where we work, earn our salary,
socialize, enjoy family life, and so forth, there are also
multiple other realities that take us away from everyday
reality. If, for example, I read a novel, or go to the theatre or
the cinema, or play a video game, I spend a couple of hours
escaping into a different sort of reality which opens up in

the pages, on the stage, or on the screen. In such realities, I

may not have a role to play as myself, and I may identify
with one or more of the characters presented in these
different media. In dreams or even daydreams or various
fantasies, I may more actively play a part as myself, or as a
modified variation of myself, but not one that I usually
play in my everyday reality.
Developing Gallagher's idea, we suggest that
delusion can be interpreted as a fall of the subject in an
aberrant role of a fictional scenario. He is not able to
return to his basic condition; he identifies himself with a
fictional hero and he thinks and acts by the logics of the
fictional world, different from the everyday life. This
idea, which has not been systematically developed so far,
can be correlated with the existent studies regarding the
narrative psychology of the person, developed by
Tomkins, Hermans, McAdams (8, Note 1). The issue of
the MR is still under discussion. Important references to
this theme can be found in the writings of Mircea Eliade
(9, 10 Note 2). Eliade discusses the difference between the
sacral and profane time. He believes that the fictional
realities can be placed near to the special area of the
anthropological temporality, exemplified by the mythical
and sacral narration. The sacral world is a reality for
people who believe in God and it deserves special
attention. This type of reality is not mentioned in
Gallagher's examples.
The religious delusion and its particularities.
From this perspective, the religious delusion is of
particular interest. It can be considered one of the three
main delusional themes, the other two referring to the
social interpersonal relationships (paranoid, erotomanic
delusion, delusion of jealousy, of surveillance) and the
person's attitude towards his identity and state of being
(preoccupation for disease, for the body image, positive
or negative abilities, invention, particular filiation, new
identity). The religious delusion is only vaguely

Senior Psychiatrist, MD, PhD, University Professor, Department of Psychiatry, Victor Babes University of Medicine and Pharmacy, Eduard Pamfil
Psychiatric University Clinic, 21 I. Vacarescu, Timisoara, 300128, Romania. Correspondence e-mail: mlazarescu39@yahoo.com
2
Statistician, Eduard Pamfil Psychiatric University Clinic, 21 I. Vacarescu, Timisoara, 300128, Romania.
3
Resident in Psychiatry, MD, Eduard Pamfil Psychiatric University Clinic, 21 I. Vacarescu, Timisoara, 300128, Romania.
Received January 14, 2016, Revised January 15, 2016, Accepted January 18, 2016

39

Mircea Lzrescu, Jenica Blajovan, Marinela Hurmuz: The Religious Delusion And The multiple Realities
Perspective
mentioned in the manuals of diagnosis and it is less studied
than the other types of delusions (11,12, 13). Sims (14)
discussed the religious delusion from a
psychopathological point of view. This theme has been
less common during the 20th century in western
civilization (15). The religious delusion can be found in
most of the psychotic disorders, especially in
schizophrenia (16,17,18,19,20,21), delusional persistent
disorder and bipolar disorder. It is more frequently
expressed through a special mission given to the patient by
God for fighting the evil or saving the world. It is
sometimes accompanied by his identification with one of
the divine figures. The presence of the devil can be
experienced as body possession or through thought and
behaviour influence (22).
A special feature of the religious delusion is the
fact that it refers to a supernatural reality which is
organized in a mythical, narrative way and it is
traditionally, socially and culturally admitted as a special
reality. The sacral figure is accepted by official
institutions and current community practices. The sacral
universe is an undoubted reality for the normal believer,
which is parallel with the physical and social everyday
reality. It is a far away, transcendent reality. The access to
this reality is possible through individual and collective
prayers. The characters of this world are omnipotent in
relation to humans and they have access to one's intimate
life.
In Christianity, the main characters are God,
Jesus Christ, the Holy Spirit, Virgin Mary, who have
family-like relationships. In addition, there is the Devil.
The main event is the Death and Resurrection of Jesus.
The most important themes are: fighting against the devil,
saving humankind, the End of the World. God takes care
of man, he protects him and can send him special
messages and missions. The religious delusion is, by
definition, a relational one, expressing the subject's
relation to the supernatural, omnipotent characters. The
profane relational delusion in the paranoid disorder refers
to hostility, surveillance, cheating etc., exceptions being
only the erotomanic delusion and the undefined
descendancy. As a whole, the social relationships develop
on an intimate-public diagram. In regard to the sacral,
mythical characters, they are, by definition, in a faraway
place and they can only be approached indirectly. In
delusion, they get closer to the subject and they can
directly act upon him.
The sacral mythical scenario, the multiple
realities (MR) theme and delusion.
The multiple realities hypothesis refers, in Gallagher's
description, to the cultural narrative universe of the
theatre, literature, novels, virtual reality. The mythical
reality is not mentioned.
The characters of the narrative worlds theatre,
literature, history, biography are placed in an
intermediate position in relation to the physical social
reality of the everyday life. Generally, they are part of the
profane reality and they are not characterized by
omnipotence, like the characters of the sacral world. In
these multiple cultural worlds, we can identify some
areas that are closer to the supernatural reality (e.g.
witches, aliens) and other closer to the common existence
(historical characters, biographical heroes). The sacral
40

instance is traditionally an originary, world-creating

reality. This is the reason why the religious delusion is a
special delusional theme which might have a psychoanthropological value that can clarify some aspects of this
psychopathologic syndrome.

In delusion, as well as in other

psychopathological states, the psyche's structures undifferentiate themselves, affecting the specific
anthropologic spatiality, temporality, causality and the
identitary structure of the subject. Temporality is centred
by the present time, which lies between the remembered
past and projected future. Spatiality refers to the
anthropological distance on the intimate-public axis and
to the objective closeness. Causality implies the origin and
occurrence of a phenomenon and the way of action,
including thinking and language. The subject's identity
has a complex structure. It includes his social identity
(name, identity card, marital and professional status,
biography), his subjective belonging to the self, the
differentiation from others and the environment and the
sense of agency and ownership of his experiences.
Moreover, it implies the global feeling of self-identity.
The impairment in all these areas needs to be explored in
delusion.
MATERIAL AND METHOD
The paper analyses 12 cases of religious
delusion. They are part of the Case Register for Psychosis
Timisoara. The register includes a total number of 1618
new cases of psychosis during the period 1985-2004, out
of which 728 cases are still under observation. This
sample has been analysed with different aims until
present. During their evolution, 225 cases presented
religious delusion.
The purpose of the study is to analyse and
understand the religious delusion from the MR
perspective. The paper does not discuss the statistical
clinical and evolutional characteristics, but the
phenomenological aspects of the 12 cases. The subjects
present religious delusion characterized by grandiosity
ideas of special mission given by God or identification
with mythical and sacral characters. We try to analyse the
depersonalization/trans-personalization process of
delusion. This process transforms the subject in a special
character a character of the sacral reality, if we consider
the particular atmosphere of the religious delusion - but
also in other historical or fictional characters, in cases

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

concerning other types of delusions.
Case studies
Case 1. A 41-year-old woman developed a psychotic
symptomatology with manic disinhibition and delusion of
divine mission: She is chosen by God and she has the
mission to fight the devil. God talks to her every day. The
Holy Spirit is talking through me. God has chosen her to
be a prophet, because she is clean, she does not lie, she
has not committed adultery and she has, on the back of her
hand, a sign indicating the place of the nail from Jesus'
crucifixion... She has a bitter taste in her mouth from the
wormwood Jesus had to drink and her body smells like
incense. God protects her and influences her, she has
thoughts which are given by God, her thoughts can be
read with God's help. She feels she is being followed by
people, because people are devils, she realized that and
she feels a cold shiver in her back head.
Delusion of divine mission is correlated with the
identification with Jesus; her mission is similar to the one
of a prophet. Her intimacy with divinity expresses through
thought broadcasting and influence. The religious
scenario expands to her relationships with other people,
which are devils. In most of religious delusion cases,
there are particular aspects of Schneider's first rank
symptoms. This deserves a special discussion, the current
analysis referring to the identitary-relational problem. Her
special mission and identification with Jesus places the
patient in the supernatural world. She feels protected by
God, in the same way a child is protected by his parent
against other people's harm. This closeness and familial
intimacy gives a natural explanation to thought
broadcasting and insertion, if we consider the fact that
every parent can know and influence his child's thoughts.
Case 2. A 42-year-old woman develops a religious
delusion... she feels that God is inside her and He speaks
through her mouth...she has to pray for the whole
world...she feels that she is charmed by her neighbours
and mother-in-law, who want to harm her and she feels the
para-psychological influences... Jesus speaks through
her voice...she can do anything.
Even if the identification with God and the special mission
are present, people are also part of her scenario. However,
they are also contaminated by the supernatural world
which the patient has entered, because they are able of
doing charms. The identification with a divine character is
suggested by the fact that Jesus borrows her speech and
assures her omnipotence.
Case 3. A 44-yyear-old man has a slow onset of psychosis,
during a 2 year period, presenting a delusion of
grandiosity: he feels that he has been sent on earth by God,
he feels Jesus in his body and he has the mission to save the
world from disasters. He has special powers which he uses
for people's benefit; he is a visionary, everything he thinks
happens. That is why he avoids reading negative articles in
the media or thinking about them. When he walks on the
street, people want to touch him in order to steal his
energy, because he has supernatural powers; the people
follow him on the street. He is also monitored through the
radio and TV. When he had crossed the country border, a
storm started: it was a divine sign which has warned him
not to leave the country. When he looks at the moon or at
the Bible, he sees God, the angels and all the saints.
Delusion of special abilities correlates with the special
mission and identification with Jesus. His extraordinary

capacities are not oriented towards fighting the devil, but

they can influence human nature and behaviours. He has
common supernatural capacities for someone who is
part of the divine world. People follow him on the streets
and through the radio. The subject lives in a supernatural
universe, where he is in an intimate relationship with the
biblical characters. But this is something usual for
someone who is at the same level with Jesus, whom he
feels inside his body.
Case 4. A 22-year-old man believes that he is the Son of
God and he has to give people presents, bread, fish... he
considers himself the chief of the Foreign Legion and he
owns the files of the Timisoara Revolution...he will play in
a porn movie...he will buy the Psychiatric Clinic where he
is admitted and he will give the clinic his name. He
preaches the voice of God and he will go to Heaven
because his soul is clean and he has no sins.
The attribute of being the Son of God is combined, in an
imaginary and meta-representational way, with other
megalomanic social and political roles. By entering the
delusional world, the subject can become a character in
fictional scenarios. The religious scenario and the role of
the Son of God are in the main place. But the subject can
also develop other roles and scenarios, closer to the world
he is living in. Thus, the identitary role of the Son of God
may associate with other identities which can develop in a
narrative fictional scenario.
Case 5. A 44-year-old man, during a 3 month onset of
psychosis, perceives and interprets different signs which
tell him that he has to become a believer... he is sure than
the end of the world will be in 7 months, that God sends
signs which only a few persons can understand. While
waiting the end of the world, he refuses food and he only
drinks water from a fountain in front of a church, which he
has dreamed and has been guided to. He is sent by God, he
understood from the signs that he will be crucified in the
front of the Cathedral in Timisoara, he is guided by the
divine power and he can hear his own thoughts. God
shows him in his dreams persons who need him to cure
them and he shows us two persons which he has already
cured through the power of his hands and faith.
The new identity of the subject, the God's chosen one,
allows him to understand the hidden signs showing the end
of the world. The identitary transformation goes even
further, towards an imitation Christi, crucified in the
front of the Cathedral in his home town. Schneider's first
rank symptoms develop in this fictional atmosphere.
Case 6. A 32-year-old man develops a delusion of
jealousy, he feels followed and watched on the street, then
he believes that he is charmed... Later, a religious
grandiosity delusion develops: I am the light of the
world, I was sent on earth by God. At Easter, everybody
can take light from my angel halo...I am a very important
person, everybody has heard about me. Satan takes the
neighbours' image in order to monitor me, I don't know
with whom I am talking to any more.
The grandiosity expresses itself in a metaphoric speech (I
am the world's light). The paranoid delusion is correlated
with jealousy, sensitivity, charming and demonic
delusions.
Case 7. A 41-year-old woman has a first-episode
psychosis with paranoid delusion, symptoms of thought
broadcasting and auditory hallucinations. In the second
episode, a grandiosity religious delusion emerges: I am
equal to God. The paranoid symptoms are less expressed.
41

Mircea Lzrescu, Jenica Blajovan, Marinela Hurmuz: The Religious Delusion And The multiple Realities
Perspective
The relationship with divinity is not necessarily one of
subordination, mission or identification; the main aspect
is that the patient is part of the same world as God. He has
the same position, he is his equal. In most cases, the
identitary scenario is explicitly expressed.
Case 8. A 35-year-old woman presents paranoid
delusional episodes (2001,2002)- delusions of
persecution, poisoning, but also religious delusion: she
feels a power descending upon her while she is praying.
At the second admission in the hospital, she says: Jesus
lives through me, I am Virgin Mary and she calls her
husband Joseph or Avram.
Case 9. A 54-year-old woman develops a grandiosity
religious delusion, declaring I am God, in the same time
with a paranoid delusion: she believes that she is followed
by the police and security services, that her grandmother
was substituted with a spy and she reports her to the police.
She believes that the president and the head of the church
are her children.
The identitary aspect does not only refer to the patient's
person, but also to the substitution of her grandmother.
The delusion develops as a narrative scenario which
includes real, important characters, who become her
children.
Case 10. A 19-year-old man has a psychotic episode with
religious grandiosity: he is an important person, because
the Holy Spirit has descended upon him, he will save the
country form a disaster, people watch him in a particular
way because of his importance. In the city, there is a
witch who surveys him and knows his thoughts,
everybody can read his thoughts through the radio and
TV, he can influence the Romanian football team by
only pronouncing the word attacker. The devils' army
has 999 million members, and if we turn the number
upside down, it becomes 666-the devil's number. He does
not get out of the house because in the kingdom there is
only modern science, there are no flowers or trees. As a
child, an army of devils wanted to harm him, they pushed
him in the devil thesaurus, he hurt his head and he has been
feeling bad ever since. The devil controls his thoughts;
the whole town, the whole country knows his thoughts.
He is an important person, an Emperor or a Commander;
his mother got pregnant with the Emperor, in the same way
as Virgin Mary had and this is the way he was born. The
Emperor will send a ship to take him home...or to the
Kingdom or to Heaven, he does not know exactly
where... he fought the devils and he won...he became
free.
The religious and grandiosity delusions develop in a
narrative form, with fairytale elements. His father is an
emperor and he was born in the same way Jesus was born.
The transposing of one's identity in the fictional
narrativity constructs a narrative character who detaches
form the bodily self in the present person.
Case 11. A 33-year-old man develops grandiosity
religious ideas, having a bizarre behaviour. He is sure that
he has a new identity, inspired by the historical literature.
He is the good soul of Napoleon, whose uniform he will
wear, and he will speak on his behalf. His soul has more
covers, he is a genius, he is the people's man, a saint, his
mission is to unify the catholic and orthodox churches, so
that the people will pray to the East... He refuses to eat
and he forces his family to do the same in order to purify
themselves and become superior beings... He is
42

suspicious, nervous and he walks out in a careless outfit.

During another admission, he feels he is chosen by God,
having the mission to bring peace and wellbeing on
earth...he has special relationships with the supernatural
forces...he is chosen by God to rule the world at the end of
it...he is in an inner continuous fight in his relationships
with God, Lucifer, the demons and the angels.
When psychosis manifests throughout the grandiosity
delusion, the patient's identity is modified, sometimes
embracing the soul of a historical character; but,
essentially, his identity is placed in a supernatural
existence, in a relationship with divine characters. He is
not only imagining them; they are part of the world the
patient is living in.
Case 12. A 22-year-old man develops psychotic
symptomatology: at a certain moment, he sees Jesus
waving; he was dressed in white and blue and, from that
moment on, these colours gain a special meaning for
him... Everything that happens is related to him and his
intentions... There are references to his life on TV, because
his thoughts and intentions are known and someone
probably the director of the movie inspired by his life
influences his behaviour and thought... He believes that
his body is signed, at the level of his heart and hand,
probably by God... His mother is not his real mother, but a
woman who lives with him in the same house. Nor his
father is the real one; his father is God or the director of the
movie Sunset Beach; he is the main character of this
series. He is smarter than the others around him and
nobody can understand him.
The patient has an indirect relationship with Jesus, who
only appears as an illusion of a person in the context of a
delusional perception which leads to delusion. In this
state, his identity changes: his parents are not the real ones,
he is probably the Son of God, but he could also be the son
of a movie director, in which he believes he is the main
character. The delusion partially develops through a
fictional, but worldly identity, as a movie hero.
DISCUSSION
The religious delusion is often centred by the
theme of grandiosity, including a special mission received
by God for fighting the evil, defeating the devil or saving
the world. Sometimes, this special mission can derive
from the feeling of having an extraordinary capacity and
omnipotence. In most of the clinical cases, the grandiosity
in the religious delusion is rarely accompanied by other
manic bio-psychological symptoms: the acceleration of
psycho-motricity with hyperactivity, logorea, insomnia,
agitation, sexual disinhibition etc. It is correlated with the
superior level of the supernatural world. The subject feels
that he enters and becomes part of this world through his
identity and mission. Thus, he identifies himself with a
special role. God can talk to the subject, can give him a
special mission or He can send him divine signs. Often, a
process of identification takes place, the subject feels that
he is the Son of God. Therefore, he receives a divine
position. The subject can declare: I am Jesus Christ, I
am Virgin Mary, I am God. The identitary
transposition places the subject into the role of a divine
character. A patient says: I sometimes feel I am God and
other times the Devil. It is a process of transpersonalization that makes the subject part of the
supernatural universe. Traditionally, the notion of

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

demonic possession is also used. It is not only correlated
with delusion, but also with the dissociative and trance
states. In the religious delusion, we can talk about
possession by divine figures God, Jesus, Virgin Mary,
the Holy Spirit. However, this supernatural possession
takes place in the context of intimacy with the sacral
world. The religious delusion highlights the transpersonalization lived by the subject when he enters the
delusional world. He becomes a different character who
is involved in the scenarios of a different world.
Another important aspect is the fictional
narrative characteristic of the religious experiences. The
subject enters a fictional world, a world of narrativity,
history and stories. Mircea Eliade (10) considered that
each sacral mythology is a narration, a sacral story with
characters and events. In the religious delusion, the sacral
characters fall in a familiar, everyday lifestyle and
relationships; hence, the divine myth becomes similar to
the narrations of the everyday life, which particularly
characterizes the multiple realities of culture and
history. Not only Don Quijote can identify himself with
different heroes. From this point of view, Eliade considers
that the time of the profane narration of the novels
derives from the special time of the sacral narration.
Therefore, delusion can be interpreted as the
falling of the subject in a narrative scenario in which he
identifies himself with a fictional aberrant role; and not
only an impairment of the cognitive processes of
interpretation. He cannot leave the delusional fiction in
the way a person can abandon a prayer, a lecture or a
theatre play. The deluded person is absolutely convinced
of his false idea, similarly to the conviction of a believer in
divinity.
Unlike religious delusion, the paranoid delusion
or the monothematic systematized one hypochondriac,
dismorphophobic, jealousy, erotoman, relational delusion
do not suggest, at first sight, the self-identification with a
role or a character from a narrative fictional scenario.
However, we can also talk about roles in these cases. The
patient focuses his existence on a role derived from the
social roles discussed by Pearson's sociology. From this
traditional sociological perspective, the social roles do not
only refer to the social statuses: gender roles, age roles
(child, adolescent, adult, old man), professional and
marital roles (engaged, married, divorced, widow). The
sociologic doctrine also accepts transitory roles, such as
the role of a sick, cheated, surveyed, persecuted person,
the last one being real in the totalitarian regimes. Most of
the monothematic delusions can be interpreted as an
identitary disorder in which the subject falls into the
identification with this kind of roles. Nevertheless, in
these cases, the process of depersonalization/transpersonalization and the fictional feature of these scenarios
are not obvious. Concerning the paranoid delusion in the
schizophrenic form, the fictional scenario of the
delusional universe sometimes becomes more obvious.
For example, when the subject feels that he is controlled
by aliens. Still, in the case of schizophrenia, the
depersonalization phenomenon has special
characteristics, with the loss of self-borders and the
fragmentation of the self, this aspect makes the process of
trans-personalization difficult. The person having
schizophrenia frequently feels like an abstract character;
or, as suggested by Stanghellini, a spirit without a body, a
simple entity, impersonally monitored and controlled

(23).
The religious delusion gives us an important
suggestion regarding the trans-personalization process in
the psychopathology of delusion. The subject enters a role
in an aberrant fictional scenario. These aspects can lead to
important analyses in the psychopathology of delusion,
especially because, at this level, we can discuss the
differences and correlations between faith and belief.
CONCLUSIONS
The approach of religious delusion from the
perspective of Gallagher's multiple realities suggests a
process of depersonalization/trans-personalization which
leads to the subject's identification with a role in an
aberrant scenario, in a fictional world. The fictional aspect
that characterizes the sacral universe in delusion is the
consequence of a deficit and psychic de-differentiation
induced by psychosis. If we interpret the cases of religious
delusion from this perspective, we need to pay attention to
the multiple realities fictional realities closely
connected to the everyday life, such as the reality of the
theatre, novels or virtual computer world. By describing
delusion as the fall of the subject in an aberrant role, the
existentialist-phenomenological theme of being in the
world is reviewed. This concept was approached by
Heidegger in his book Being and Time and it has
inspired the phenomenological psychopathology,
especially Binswager's approach in the field of delusion
(24). When discussing the multiple realities, Gallagher
explicitly highlights this concept. It is an idea that has
always been expressed during time by Kraus'
phenomenological-anthropological analyses (25).
Note 1
The narrative psychology of the person considers
the self as being involved in different narrations: one's
own narration about himself in various situations; but also
other's narrations of himself. The narrative self expresses
by reference to the lived episodes of different durations
and has its fundaments on the identitary structure of the
person. From Dennett's perspective, this structure is the
centre of the lived and narrated experiences. Tomkins
suggested that the person can be interpreted through the
role he plays in different scenarios which he develops for
different situational problems. Hermans discussed the
existence of several simultaneous voices of the subject.
These psycho-sociological interpretations of the person
develop an older idea of James (1890) regarding the
multiplicity of the subject's selves. This view (of a subject
playing roles in different scenarios) is in concordance with
Gallagher's perspective of multiple worlds.
Note 2
Mircea Eiade developed the idea of the
difference between the sacral and profane time. The
mythic history that forms the base of a religious belief is
considered to take place in a faraway time, in the sacral
time of the beginnings and creation. During the religious
rituals, people leave the profane time of work and
everyday preoccupations and enter the mythic time of the
origins. After that, they spend a short time of celebration,
which is also different from the profane time. The
religious ceremony can be considered the prototype of all
human celebrations. Eliade suggests that there is a third
type of time related to the time of the myth the time in
which the persons recall the historical events and stories
that funded the culture and society they live in; and the
43

Mircea Lzrescu, Jenica Blajovan, Marinela Hurmuz: The Religious Delusion And The multiple Realities
Perspective
time of the fictional narrations experienced while reading
or listening to a story or novel. This reference to the
mythic-narrative time is comprehensively connected to
the doctrine of the multiple worlds/realities.
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***

REVIEW ARTICLES

ANTIPSYCHOTIC TREATMENT AND

PSYCHOSOCIAL FUNCTIONING IN
SCHIZOPHRENIA RESULTS FROM ROMANIAN
COHORT OF EUFEST STUDY
Valentin P. Matei, Alexandra Mihailescu2, Traian Purnichi3,
Ruxandra M. Al-Bataineh4
Abstract:
Introduction: Schizophrenia represents a chronic and
debilitating illness listed by the international organisms as
top priority for public health actions to reduce disability
and improve the function and quality of life for people
living with chronic illness.
Objective: The aim of this study was to compare
psychosocial functioning of schizophrenic patients after 1
year of neuroleptic treatment in a first episode
schizophrenia population treated with atypical or typical
antipsychotics.
Methods: Procedures of the European First Episode
Schizophrenia Trial study (EUFEST) have been previously
described. Data analyzed in this paper refers to Romanian
patients (N = 113) included in the EUFEST study.
Psychosocial functioning was assessed by Global
Assessment of Functioning (GAF). GAF questionnaire
was applied at baseline and at 1, 2, 3, 6, 9 and 12 months
(end of study).
Results: Mean value at 1 year compared with baseline was
76.88 (16.20) vs. 39.06 (13.56) for Haloperidol, 75.58

(18.41) vs. 40.67 (12.71) for Olanzapine, 78.57

(10.15) vs. 37.65 (17.05) for Quetiapine, 82.35 (10.16)
vs. 38.24 (12.52) for Amisulpride, 76.11 (9.47) vs. 38.33
(10.26) for Ziprasidone. Statistical comparison with
ANOVA revealed no statistically significant differences, p
= 0.533. The improvement in functionality in patients did
not differ between antipsychotics from one evaluation to
another. During the antipsychotic treatment, the
psychosocial functioning of patients improved
significantly more during the first 6 months, irrespective of
treatment arms. After that, the improvement continued to
develop, but at a slower pace.
Conclusions: Our study didn't support the superiority of
atypical neuroleptics versus classical ones regarding
functionality in first episode schizophrenic patients. The
improvement starts fast with both classes of drugs and the
larger part of improvement in functionality took part
during the first 36 months of treatment.
Key words: Antipsychotic, functionality, first episode
schizophrenia

INTRODUCTION
All chronic illnesses have the tendency to limit or even
decrease the functional status of people that live with them,
which is reflected in all life domains: psychological
(accurate understanding and interpretation of people's
behavior), social (performing a social role), occupational
(capacity to perform obligations at workplace, school and
so on), leisure (capacity to enjoy spending time doing
things that you like). Therefore the quest to achieve a better
living for people having a chronic disease, it is of
paramount importance and is in line with the current
Schizophrenia,
healthy-longevity promotion (1).
dementia and depression represent chronic and
debilitating illnesses listed by the international organisms
as top priority for public health actions to reduce disability
and improve the function and quality of life for people
living with chronic illness (2).
Schizophrenia is a heterogeneous clinical syndrome,
including positive and negative features and
neuropsychological impairment, also having impaired
social and occupational functioning as a core
characteristic.

There is an important debate about how much

each dimension contributes to functionality of
schizophrenia patients with the bulk of the data (3, 4, 5)
suggesting that cognitive and negative symptoms
decisively participate in long term functionality of
schizophrenic patients. Both Kraepelin and Bleuler were
aware that positive symptoms do not represent the core of
schizophrenia. Of course treating positive symptoms still
represents an important part of the management of
schizophrenia, but by no means equals the most important
part. During the acute phase of schizophrenia the patient
may act in way which can be extremely deleterious for his
social, professional or familial relationships not to
mention direct threats of personal health or even life (i.e.
during an acute exacerbation of symptoms one patient
having command auditory hallucinations may act on them
and kill himself etc., etc).
Reduction of positive symptoms has been therefore an
important goal in schizophrenia therapy since the
beginnings of drug treatment developments, despite the
fact that very soon clinicians became painfully aware of
the importance of treating negative and cognitive

MD, PhD; Clinical Psychiatric Hospital Prof. Dr. Al. Obregia,2nd Dept.; UMF Carol Davila,Bucharest.
MD, PhD; Clinical Psychiatric Hospital Prof. Dr. Al. Obregia,1st Dept.; UMF Carol Davila,Bucharest.
3
MD; Clinical Psychiatric Hospital Prof. Dr. Al. Obregia, 7th Dept.
4
MD; Clinical Psychiatric Hospital Prof. Dr. Al. Obregia, 2nd Dept.
Corresponding author: Valentin Matei, vm_matei@yahoo.com
Received February 1, 2016, Revised February 12, 2016, Accepted March 8, 2016
2

45

Valentin P. Matei, Alexandra Mihailescu, Traian Purnichi, Ruxandra M. Al-bataineh: Antipsychotic Treatment And
Psychosocial Functioning In Schizophrenia Results From Romanian Cohort Of Eufest Study
symptoms, as key goals for a better functioning of the
patients.
Guidelines for treatment in schizophrenia recommend
that primary treatment should be pharmacological,
antipsychotics representing the mainstay of the treatment
(6). Antipsychotics are currently classified into: first
generation, conventional or 'typical' antipsychotics
(FGAs), second generation 'atypical' antipsychotics
(SGAs) (7). Both classes of antipsychotics are targeting
positive symptoms in schizophrenia and are capable of
inducing extrapyramidal symptoms (EPS), however,
atypical antipsychotics have some evidences regarding
efficacy on negative and cognitive symptoms (8),
although the mean effect is recognized to be small (9, 10)
and are known for inducing less EPS but instead are
associated with an increased risk for metabolic syndrome
(11).
Recent studies challenge (12,13), the initial optimism that
atypical antipsychotics are indeed associated with an
improvement in negative or cognitive symptoms despite
the fact that are authors who consider that a superiority in
functionality in the case of patients treated with atypical
antipsychotics compared with patients treated with
conventional antipsychotics appear after a longer time of
treatment (14).
Future research should aim to determine the most feasible
and valid measure of functional status in schizophrenia, as
we set as a target for treatment functional recovery.
Efficacy of antipsychotics has been quantified by complex
analyses of scores in scales of symptoms reduction, like
PANSS (15, 16), but also by all-cause treatment
discontinuation - the EUFEST and CATIE studies (13,
17), and quality of life the CUtLASS study (18).
The most important goal of antipsychotic treatment in
psychotic diseases is functional recovery (19).
Assessment of functional status might represent a better
indicator of overall status of a certain schizophrenic
patient than psychometric tests that assess symptoms.
Psychosocial functioning is strongly correlated with
cognition and negative symptoms, but these domains are
currently poorly targeted by schizophrenia treatment. The
development of atypical antipsychotics was considered a
very important step in the treatment of schizophrenic
patients and a great hope at that moment also for
improving psychosocial functioning. Atypical
antipsychotics were created and proved to have less EPS
and sedation which could have made instrumental daily
activities easier; also improvement on negative symptoms
could have made the patient to regain interest and
initiative.
However, the results of later studies weren't so optimistic.
The latest data comparing typical and atypical
neuroleptics in schizophrenia treatment didn't reveal
important differences between the 2 classes of
antipsychotics regarding efficacy in improving cognitive
and negative symptoms (9, 13).
Clinical trials mostly assess efficacy (reduction of
symptoms), which is less easy extrapolated to real life. In
order to clearly define benefits of antipsychotics in
treatment of schizophrenia, a study should assess
effectiveness or achievement of functional outcomes,
since this could make the study more real-life oriented.
There are still scarce data on effectiveness of
schizophrenia treatments.
46

Most clinical trials have used for establishing efficacy of

an antipsychotic and subsequent marketing have included
a selected patient population, too few women and subjects
with comorbid conditions, which may not be a good
reflection of patients seen in everyday practice (20). In
order to overcome these drawbacks, large project trials
like CATIE, Cafe, SOHO, CUtLASS, EUFEST have been
designed in a naturalistic manner, in order to assess also
effectiveness of antipsychotics, which means efficacy
plus tolerability (21).
EUFEST trial is one of the most valuable naturalistic
studies which assess effectiveness of antipsychotics in
recovery of functional status because it includes first
episode and treatment naive patients. EUFEST study has
used DSM IV axis V evaluation of functionality - the
Global Assessment of Functioning (GAF) scale (22).
Although in present, the DSM V is recommending use of
WHODAS as a global measure of disability in psychiatric
disorders, the use of GAF has been proven throughout a
decade of studies a simple and reliable measure of
functional status (23).
Attitudes towards schizophrenia treatment have changed
in view of recent neurobehavioral and epidemiological
researches, which are showing that action directed
towards improving functional status can have a profound
impact on its onset and outcome (24). By assessing and
evaluating psychosocial functioning in schizophrenic
patients, it may be possible to determine the clinical status
of a patient under treatment with antipsychotics.
To address this issues, we analyzed data from EUFEST
study (Romanian patients) relating to functional status of
patients with first episode schizophrenia after 1 year of
antipsychotic treatment. We also compared the efficacy of
treatment on functional outcome across classes of drugs,
between atypical and typical antipsychotics.
METHODS
Data analyzed in our paper are drawn from European First
Episode Schizophrenia Trial study (EUFEST).
The purpose of EUFEST study (25) was to compare
atypical antipsychotics (amisulpride 200800 mg/d,
olanzapine 520 mg/d, quetiapine 200750 mg/d,
ziprasidone 40160 mg/d) with low doses of typical
neuroleptics (haloperidol 14 mg/d) in terms of
effectiveness. The measure for effectiveness in EUFEST
is all-cause treatment discontinuation, defined as the time
to discontinuation of the study drug to which patients were
originally randomized.
Investigators from 50 centers in Europe and Israel
participated into this trial. Eligible patients were 18 40
years of age and met DSM- IV criteria for schizophrenia,
schizophreniform, or schizoaffective disorder confirmed
by the Mini International Neuropsychiatric Interview
Plus.
Inclusion criteria were: 18 40 years of age and DSM- IV
criteria for schizophrenia, schizophreniform, or
schizoaffective disorder confirmed by the Mini
International Neuropsychiatric Interview Plus, first
episode of disease with no more than 2 years elapsed
between the onset of positive symptoms and recruitment
into the trial and previous use of antipsychotic drugs of
less than 2 weeks during the preceding year and less than 6
weeks lifetime.
The investigators invited eligible patients to participate

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

providing information orally and in writing about the trial.
After complete description of the study to the subjects,
written informed consent was obtained. The trial complied
with the Declaration of Helsinki and was approved by the
Ethics Committees of the participating centres.
Patients did not meet exclusion criteria in this study if: no
more than 2 years elapsed since the onset of positive
symptoms; any antipsychotic have not been used
exceeding 2 weeks in the previous year or 6 weeks
lifetime; patients had not a known intolerance to one of the
study drugs; and patients didn't meet any of the
contraindications for any of the study drugs as mentioned
in the (local) package insert texts.
Baseline data were obtained between 4 weeks before and 1
week after randomization on demographics, diagnoses,
current medication, psychopathology (Positive and
Negative Syndrome Scale - PANSS), severity of illness
(clinical global impression - CGI), overall psychosocial
functioning (global assessment of functioning scale GAF), extrapyramidal symptoms (St Hans rating scale SHRS), depression (Calgary Depression Schizophrenia
Scale - CDSS),
neurocognitive performance (six
measures: Trail Making A [time], Flexibility Index [Trail
Making BA time], Wechsler Adult Intelligence Scale
Digit-symbol Coding [total correct], Purdue pegboard
[total pegs with dominant hand], Rey Auditory Verbal
Learning Test learning index [total correct on trials IV],
and Rey Auditory Verbal Learning Test secondary
memory [total correct on Delayed Recall trial]), and
quality of life (Manchester Short Assessment of Quality of
Life - MANSA).
All scales have been given to the included patients at
Baseline, 1, 2, 3, 6, 9, and 12 months. Data about quality of
life were evaluated at baseline, month 3 and end of study
(month 12).
In this article we used the term 'schizophrenia' for
diagnostics of schizophrenia, schizophreniform and
schizoaffective disorder.
Data analyzed in my paper refer to Romanians patients
(N=113) included in this study.
STATISTICAL ANALYSIS
We used descriptive analysis to characterize
demographics and repartition into treatment arms. Mean,
SD, and sample size are provided for continuous
variables. Discrete variables are described using
frequencies and percentages. All statistical tests were 2
tailed; (level of significance) was 5%. Discrete variables
were analyzed with a 2 test. The differences between
different treatment arms (Haloperidol, Olanzapine,
Amisulpride, Quetiapine, Ziprasidone) were assessed
using ANOVA function and corrected with Bonferonni ttests. Within-group improvement in GAF scores over time
was evaluated using paired-sample t tests.
Concerning cognitive functioning, for simplicity a
composite score of cognitive functioning was created,
after standardizing to create z scores and obtaining the
mean for standardized values on the neurocognitive tests.
Data were analysed using Statistical Package for Social
Sciences (SPSS) version 16.
RESULTS
The EUFEST study in Romania included 113 patients
which were randomized to one of the treatment arms.
From the 113 initial randomized, 61 (54%) are women and

52 (46%) men.
GAF scale was applied by clinicians at baseline, 1, 2, 3, 6,
9, and 12 month (end of study).
Of the 113 patients in Romanian cohort of EUFEST study,
2 patients did not have valid baseline data and 20 patients
did not complete the study. We analysed sociodemographical and clinical characteristics differences
between completers and non-completers, because people
who didn't finish the study might be different (and
therefore could reduce the reliability of results) from
people who completed the study. We found that noncompleters were more frequently (significantly statistic)
having an occupation and reported a better Quality of Life
(significantly statistic) comparing with completers,
without any other differences. Data are presented in table
1.

Agea
Education (in
years) a
Genderb
Married (yes) b
Having an
occupation (yes) b
Composite
cognitive score
baselinea
Functionality
(GAF baseline) a
Quality of Life
(MANSA
baseline) a
PANSS total score
(baseline) a
PANSS positive
subscale
(baseline) a
PANSS negative
subscale
(baseline) a
PANSS general
psychopathology
subscale
(baseline) a
Depression
(CDSS, baseline) a

Complet
ers
27.12
(+/-6.11)
12.33(+/2.68)
52.7%
women
21.5%
48.4%

Noncompleters
25.91 (+/5.86)
12.95 (+/3.00)
60.0%
women
15.0%
75.0%

pvalue
.419

-.02 (+/.51)

.08 (+/-39)

.463

39.83
(+/12.87)
3.90 (+/.99)

34.37 (+/12.35)

.093

4.65 (+/.80)

.002

90.25
(+/19.71)
25.28
(+/-6.02)

88.65 (+/9.82)

.725

24.95 (+/5.89)

.822

20.50
(+/-7.50)

20.40 (+/6.44)

.956

44.47
(+/10.71)

43.30 (+/6.09)

.639

5.02 (+/5.83)

3.21 (+/4.14)

.201

.363
.626
.760
.047

Statistic = t-test
Statistic= chi-square test

Table 1. Socio-demographical and clinical characteristics

of completers vs non-completers in EUFEST study
Romanian cohort
There are no differences regarding treatment arm
allocation between groups as evaluated by logistic
regression (p=.432).
A summary of data upon socio-demographics and clinical
characteristics (PANSS total score) across treatment arms
47

Valentin P. Matei, Alexandra Mihailescu, Traian Purnichi, Ruxandra M. Al-bataineh: Antipsychotic Treatment And
Psychosocial Functioning In Schizophrenia Results From Romanian Cohort Of Eufest Study
in the population analysed in this study revealed no
baseline differences (Table 2a and 2b).
Age?

Gender?
Wo
men

Men

Haloperidol

Marital
status?
Mar Not
ried mar
ried
2
16
11.1 88.9
5
22
18.5 81.5
4
14
22.2 77.8

N
18
7
11
Mean 25.65 38.9 61.1
SD
5.98
Olanzapine
N
27
15
12
Mean 26.86 55.6 44.4
SD
6.19
Quetiapine
N
18
8
10
Mean 27.02 44.4 55.6
SD
6.13
Amilsulprid N
26
13
13
4
22
e
Mean 26.92 50.0 50.0
15.4 84.6
SD
5.42
Ziprasidone
N
24
18
6
8
16
Mean 27.8
75.0 25.0
33.3 66.7
SD
6.86
Analysis
Statis F=.31
2=.717
2=39.726
tic
7
dF
4
1
1
1
p
.866
.397 .000
.000
a
No significant differences between the 5 groups (ANOVA F,
p>0.05)
b
Percentage calculated based on the total sample at baseline
c
No significant differences between the 5 groups (2, p>0.05)
d
Significant differences between the 5 groups (2, p<0.05)

Data about GAF scores during the study by

treatment arms are presented in table 3. There was no
overall difference between the five treatment groups in
GAF scores between baseline and end of study time
(F=.793, df=4, 92, p=0.533) or in-between visits (all p
values >0.05).
Change in GAF score from baseline to end of study (12
months) showed improvement in each of the five
treatment groups (Paired t-tests: haloperidol: t=-8.388,
df=16, p<0.001; olanzapine: t=-8.403, df=23, p<0.001;
quetiapine: t=-7.128, df=12, p<0.001; amisulpride: t=13.974, df=19, p<0.001; ziprasidone: t=-11.560, df=17,
p<0.001).
GAF

Halop
eridol

Olanz
apine

Quetia
pine

Amisu
lpride

Zipras
idone

P-values
between
classesa

Baselin
e

39.06
(+/13.56)

40.67
(+/12.71)

37.65
(+/17.05)

38.24
(+/12.52)

38.33
(+/10.26)

.943

Month
1

48.83
(+/16.29)

56.30
(+/16.73)

52.12
(+/13.33)

57.25
(+/15.25)

53.41
(+/11.78)

.322

Month
2

64.65
(+/8.94)

66.27
(+/14.40)

66.59
(+/11.55)

70.12
(+/14.73)

61.14
(+/13.62)

.241

Month
3

73.47
(+/8.88)

69.42
(+/13.41)

70.88
(+/11.60)

73.79
(+/13.17)

65.05
(+/14.82)

.184

Table 2.a. Socio-demographical data and repartition into

treatment arms in EUFEST study Romanian cohort

Month
6
Month
9

73.48
(+/13.56)
74.24
(+/16.79)

74.00
(+/12.30)
75.62
(+/11.46)

78.65
(+/12.16)
77.76
(+/14.26)

68.58
(+/13.29)
75.39
(+/13.67)

.051

Educ
ation
(years

79.93
(+/9.64)
77.13
(+/13.16)
76.88
(+/16.20)

75.58
(+/18.41)

78.57
(+/10.15)

82.35
(+/10.16)

76.11
(+/9.47)

.533

)?
Haloperidol

PANSS
total

Current
occupation

scores?

?
No
10
55.6

Yes
8
44.4

N
18
18
Mean 11.94 91.61
SD
1.73
20.086
Olanzapine
N
27
27
12
15
Mean 12.52 88.48
44.4 55.6
SD
3.58
15.438
Quetiapine
N
18
17
10
8
Mean 12.61 98.82
55.6 44.4
SD
2.03
26.330
Amilsulprid N
26
26
9
17
e
Mean 12.42 86.85
34.6 65.4
SD
2.84
14.488
Ziprasidone
N
24
24
12
12
Mean 12.63 87.50
50.0 50.0
SD
2.67
16.133
Analysis
Statis F=.19 F=1.39
2=.434
tic
2
2
dF
4
4
1
p
.942
.242
.510
a
No significant differences between the 5 groups (ANOVA F,
p>0.05)
b
Percentage calculated based on the total sample at baseline
c
No significant differences between the 5 groups (2, p>0.05)
d
Significant differences between the 5 groups (2, p<0.05)

Table 2.b. Socio-demographical data and repartition into

treatment arms in EUFEST study Romanian cohort
48

Month
12

.758

Table 3. GAF scores across treatment arms in EUFEST

study Romanian cohort.
The improvement in functionality in patients is presented
in graph 1. We did not note any differences between
treatment arms regarding functionality in patients at the
moment of inclusion in study. No significant differences
between treatment arms regarding functionality occurred
at any following evaluation (p>0.05 at month 1, 2, 3, 6, 9,
and 12). Controlling for multiple comparisons using
Bonferonni corrections t tests comparing the change in
GAF score from baseline to each of the visits for
haloperidol versus the other four treatment arms of
second-generation antipsychotic drugs (Olanzapine,
Amisulpride, Quetiapine and Ziprasidone) did not reveal
any significant differences. Moreover, there are no
differences in functionality between atypical
antipsychotics.
During the treatment, the functionality of
patients greatly improved during the first 6 months
irrespective of treatment arms, as it can be seen on the
graphic 1 and table 4. The improvement in functionality
had occurred faster in the first 3 months of treatment
irrespective of treatment arm. After that, the improvement
continued to develop but in slower pace

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

Paired Differences

Treatment
arm

Sig.
(2tailed
)

Meana

SD

-9.778

11.715 -3.541

17 .003

Baseline to 2 months

-24.765 15.869 -6.435

16 .000

Baseline to 3 months

-32.933 16.718 -7.629

14 .000

Baseline to 6 months

-39.400 16.957 -8.999

14 .000

Baseline to 9 months

-37.600 18.833 -7.732

14 .000

Baseline to 12 months -37.000 18.187 -8.388

olanzapine Baseline to 1 month
-15.630 14.653 -5.543

16 .000

Study period

haloperidol Baseline to 1 month

df

26 .000

Baseline to 2 months

-26.346 15.796 -8.505

25 .000

Baseline to 3 months

-28.583 15.328 -9.135

23 .000

Baseline to 6 months
Baseline to 9 months

-32.261 16.712 -9.258

-33.810 18.721 -8.276

22 .000
20 .000

Baseline to 12 months -34.500 20.113 -8.403

23 .000

quetiapine Baseline to 1 month

-14.471 14.174 -4.210

16 .001

Baseline to 2 months

-28.312 20.082 -5.639

15 .000

Baseline to 3 months

-31.400 18.837 -6.456

14 .000

Baseline to 6 months

-30.417 23.473 -4.489

11 .001

Baseline to 9 months -32.417 22.549 -4.980

Baseline to 12 months -40.000 20.232 -7.128

11 .000
12 .000

amisulpride Baseline to 1 month

-18.500 15.905 -5.698

23 .000

Baseline to 2 months

-31.609 17.398 -8.713

22 .000

Baseline to 3 months
Baseline to 6 months

-35.304 16.389 -10.331 22 .000

-40.273 14.270 -13.237 21 .000

Baseline to 9 months

-38.190 18.424 -9.499

20 .000

Baseline to 12 months -42.050 13.457 -13.974 19 .000

ziprasidone Baseline to 1 month
-14.955 12.956 -5.414 21 .000
Baseline to 2 months

-23.182 17.355 -6.265

21 .000

Baseline to 3 months

-27.571 19.444 -6.498

20 .000

Baseline to 6 months
Baseline to 9 months

-29.789 17.207 -7.547

-33.667 15.737 -9.077

18 .000
17 .000

Baseline to 12 months -37.444 13.742 -11.560 17 .000

a

all scores have increased from baseline

a
Statistic=ANOVA analysis

Table 4. GAF mean score change across treatment arms

in EUFEST study Romanian cohort

Graph 1. GAF mean score change across treatment arms.

DISCUSSION
We have found that the largest part of
improvement in psychosocial functioning in first episode
schizophrenic patients appeared during the 6 months,
afterward the improvement continued, but at a slower
pace. Moreover, from the initial greater improvement (6
months) the greatest improvement took part during the
first 3 months.

It would be interesting to observe if this trend continues

over longer time because, if this would be the case,
psychosocial functioning improvement in the first 3-6
months may represent a good predictor of long term
treatment in schizophrenia. If longer studies confirm this
trend, a clinical decision about which neuroleptic to use
for long term may be improved by information of such
type.
One limitation of our study is the fact that data are obtained
about first episode schizophrenic patients. In this kind of
patients, the clinical response and consequently the
functionality is larger than in chronic schizophrenic
patients (26, 27). Other limitation is the relatively short
duration of treatment (1 year). Longer studies would be
more informative regarding long term functional outcome
in patients treated with older versus newer antipsychotics.
Functionality of a schizophrenic patient depends on
multiple characteristics mainly (but not limited at)
premorbid functioning, cognitive functioning,
psychopathology and so on. The results of our study
suggest several observations:
1. Our study didn't support the superiority of atypical
neuroleptics versus classical ones regarding functionality,
which may represent a larger and better suited item for
clinical evolution. There is a lot of research done to prove
differences between older (typical neuroleptics) and
recent neuroleptics. The discussion about putative
superiority of atypical neuroleptics versus the typical ones
dates already for a decade (9). Recent data about clinical
advantage of atypical vs typical neuroleptic seem to
indicate that there are no important differences between
the 2 classes (28, 29). However, longer studies are needed
to validate or refute these observations.
2. The bulk of improvement of functionality in first
episode schizophrenic patients appeared during the first 6
months, afterward the improvement continues, but on a
slower pace. Moreover, from the initial greater
improvement (6 months) the greatest improvement took
part during the first 3 months. This may represent a good
indicator about long term clinical evolution of patients
treated with that specific antipsychotic and to guide long
term treatment in schizophrenic patients.
One limitation of our study is the fact that data are obtained
about first episode schizophrenic patients. In this kind of
patients, the clinical response and consequently the
functionality is larger than in chronic schizophrenic
patients (26). Other limitation is the relatively short
duration of treatment (1 year). Longer studies would be
more informative regarding long term functionality in
patients treated with older versus newer antipsychotics.
CONCLUSIONS
In first episode schizophrenic patients we did not
found statistically significant differences regarding
functionality after 1 year of treatment between typical
neuroleptics and atypical neuroleptics (without
differences at 1, 2, 3, 6, 9 and 12 months). The
improvement starts fast with both classes of drugs and the
larger part of improvement in functionality took part
during the first 3-6 months of treatment. The assessment of
functionality in first episode patient should be used in
studies with longer duration in order to investigate which
antipsychotic is best for long term use.

49

Valentin P. Matei, Alexandra Mihailescu, Traian Purnichi, Ruxandra M. Al-bataineh: Antipsychotic Treatment And
Psychosocial Functioning In Schizophrenia Results From Romanian Cohort Of Eufest Study
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***

ORIGINAL ARTICLES

DEPRESSION IN YOUNG ADULTS WITH CHRONIC

SOMATIC ILLNESS AN ANALYSIS OF 1970
BRITISH COHORT STUDY
Alexandra I. Mihailescu1, Valentin P. Matei2, Liliana V. Diaconescu3,
Ruxandra Al-Bataineh4, Traian Purnichi5
Abstract
The prevalence rate of depression occurring in people with
somatic illnesses is 3 times more than people without
somatic illnesses, but less research was conducted in this
respect for people with early onset of somatic disease.
Taking into account that the presence of depression in
chronic patients aggravates the somatic disease, leading
to a poor prognosis and higher rates of mortality it is
important to detect and treat it.
The purposes of our study are to analyse in a large cohort
(BCS-70) the risk of depression in patients with somatic
illness at early ages (less or equal 30 years).
Methods
Data used in our paper were drawn from the 1970 British
Cohort Study (BCS70). The design and conduct of this
study have been described elsewhere (1). Data for the
present paper are drawn from 30 years wave. The data
were analysed with descriptive function, chi-square and
logistic regression. All analyses were performed using
SPSS 16.
Results
At age 30, we have found 1409 people (12.7%) with
depression. From a total of 11211 people there are 860
people with hypertension (7.7%) and 109 people with
diabetes (1%). There is an increased risk of depression in
the case of people with pure hypertension or pure

diabetes (p<0.05). In the case of people with both

hypertension and diabetes, logistic regression showed that
hypertension is a risk factor for depression irrespective of
socio-economic status and diabetes (Exp(B)=1.970,
CI=1.579-2.458, p=.001).
Conclusion
The above data indicate that risk of depression is higher in
people with onset before 30 years old of hypertension and
/or diabetes. Our study did not identify an increased risk
for depression by socio economic class.
Data of our study clearly suggests that it is extremely
important that young patients with somatic diseases like
diabetes and/or hypertension should be aggressively
screened and treated for depression.
1. Butler NR, Golding J, Howlett BC. From Birth to Five: A
Study of the Health and Behaviour of a National Cohort.
Oxford: Pergamon,1985. Bynner J, Butler N, Ferri E, et
al. The design and conduct of the 19992000 surveys of the
National Child Development Study and the 1970 British
Cohort Study. UK Data Archive In: CLS Cohort Studies
Working Paper 1. London: Centre for Longitudinal
Studies, Institute of Education, University of London,
2000.
Key words: depression, chronic somatic illness, young
adult, diabetes, hypertension

Introduction
Depression represents a major cause of morbidity and
mortality (1). The prevalence of depression is increasing
(2) and by 2012 it is reported to be among the first 10
diseases causing loss of years due to disability (3).
Depression is responsible for the greatest proportion of
burden associated with non-fatal health outcomes
accounting for approximately 10% total years lived with
disability(4), more than cardiovascular disorders (2.8%),
diabetes (3.0%), or chronic respiratory diseases (6.3%) (3).
Chronic somatic illnesses are the cause of significant
burden on individuals, families, societies and countries.
Chronic somatic diseases that are frequent in the age group
18-44 years old are cardiovascular disease (most frequent
hypertension reported frequencies between 1.4%(5) and
8.7% (6)), cancer (aprox 2% prevalence (7)), diabetes

(reported frequencies 1.4%(5) to 2.6%(8)) and respiratory

diseases (aprox 4% (5)).
The most frequent chronic medical conditions associated
with depression are: heart disease (9,10), hypertension(11),
diabetes (12,13), asthma (14). The prevalence rates of
depression occurring in people with somatic illnesses is
two (15) to three (16) times more than people without
somatic illnesses. In patients with two or more chronic
medical conditions the risk of depression is six times
higher comparing with healthy persons (17).
Many studies focused on co-morbidity of depression with
one single chronic condition. Researchers found a high
prevalence of depression in people with diabetes, its rates
varying by diabetes type and among developed and
developing nations (18). The prevalence of depression in
diabetes patients may range between 2 and almost 30%

1
MD, PhD; University of Medicine and Pharmacy Carol Davila, Bucharest, Department Medical Psychology; Hospital of PsychiatryProf dr Al.
Obregia, Bucharest
2
MD, PhD; University of Medicine and Pharmacy Carol Davila, Bucharest, Department Psychiatry; Hospital of PsychiatryProf dr Al. Obregia,
Bucharest, email valipmatei@yahoo.com,
3
MD, PhD; University of Medicine and Pharmacy Carol Davila, Bucharest, Department Medical Psychology;
4
MD; Hospital of PsychiatryProf dr Al. Obregia, Bucharest
5
MD; Hospital of PsychiatryProf dr Al. Obregia, Bucharest
Received March 10, 2016, Revised March 25, 2016, Accepted May 31, 2016

51

Alexandra I. Mihailescu; Valentin P. Matei; Liliana V. Diaconescu, Ruxandra Al-bataineh, Md, Traian Purnichi :
Depression In Young Adults With Chronic Somatic Illness An Analysis Of 1970 British Cohort Study

(19-23), with higher values found in patients with type 2

diabetes (24,12) and among females with diabetes (25).
Prevalence in diabetic group age 18-44 years old is less
than 5% (8). Young adults with diabetes face difficulties
with diabetes self-management and co-morbidity with
depression is deteriorating even more diabetes adaptation
(26,27).
The burden of comorbidity
Morbidity and mortality in patients with somatic illnesses
and depression are significantly higher than in patients
with somatic illness who are not depressed. These patients
face many negative health consequences: they present
more severe somatic symptoms and complications (28),
have poor outcomes of somatic disease and more
functional disability (29), a lower quality of life (30,31), a
low treatment adherence (32,33), an increased use of
medical services (34,35) and higher heath care
costs(3638).
Co-morbid depression among patients with diabetes is
associated with poor diabetes outcomes (such as
glycaemic control), with more and greater complications
(such as diabetic retinopathy, nephropathy, neuropathy)
with functional disability (3941), with a lower quality of
life (23), with a decreased adherence(35) and with higher
healthcare costs (42).
Another relevant example is the link between
hypertension and depression. Clinical studies show that
depression is common in patients with hypertension, has a
certain influence in blood pressure control and a
significant impact on severity of hypertension (43,44).
Depressive symptoms have been found to be predictive of
hypertension in young adults (45).
The association between cardiovascular illness and
depression has multiple biological and clinical links and is
likely bidirectional. Most cited pathophysiological
mechanisms are hormonal variations, metabolic
abnormalities, hypercoagulability, increased platelet
aggregation, inflammation, and endothelial dysfunction
(46,47). Depression is most likely aggravating the
associated cardiovascular disease by impeding the
optimal care for this people.
The importance of depression detection.
Although depression has a high prevalence and it is
present in patients with chronic somatic illnesses,
depression among these patients remains often undetected
(19,37). Although depression is highly prevalent in
individuals with multimorbidity, studies on the rates and
correlates of depression in these individuals are scarce
(48).
People aged less than 30 have a prevalence of somatic
illness less than 10%, however, a chronic disease that
begins early will result in a worse overall prognosis of the
person affected (49). In this respect, our study is
attempting to study if there is an increased risk for
depression for people with two frequent somatic illnesses,
hypertension and diabetes at age 30. Because the
association between these two illnesses is quite common,
we looked at the increasing or risk for depression not only
in pure diabetes and hypertensive groups but also in
increasing the risk for depression in comorbid group (i. e.
hypertension and diabetes). Methods
Data used in our paper were drawn from the 1970 British
Cohort Study (BCS70). The 1970 British Cohort Study
(BCS70) is a cohort study that enrolled 16 567 babies born
in England, Scotland, and Wales on 5-11 April 1970
52

(50,51).
The original study focused on children health and has
successively expanded to examine physical, educational
and social development of these children. Individuals
participating in this cohort study were assessed at birth
with a 96.7% response rate and in ongoing follow-ups
using a multi-method, multi informant approach.
Participants were followed up at 5 (n = 13 135, in 1970),
10 (n = 14 875 in ), 16 (n = 11 622 in 1986), 26 (n= 9003, in
1996), 30 (n = 11 261 in 2000) and 34 (n=9656, in 2004)
years of age.
At 30 years, marked efforts were made to recruit difficultto-reach subjects (51). Data for the present paper are
drawn from 30 years wave(52).
Measure of depression. At age 30, data was collected on
the severity of depressive symptoms using The Malaise
Inventory. An overall Malaise score for a cohort member
is the sum across the individual variables, yielding a
minimum score of 0 and a maximum of 24. A score of 8 or
higher is a recommended cut-off for a depressive episode
(53).
Measure of hypertension and diabetes. Data about
somatic illnesses were obtained from patients. At age 30
people from cohort were asked:
Have you ever had or been told you had high blood
pressure?
Have you ever had diabetes?
They could respond with yes, no, don't know and
not answered. We excluded from the analysis the last 2
groups of responders.
Measure for socio-economic status. Data about social
class of people from cohort were used as proxy for socioeconomic status (ses). Social classes were defined as such:
Professional, Managerial-technical, Skilled nonmanual, Skilled manual, Partly skilled and
Unskilled.
Statistical analyses. We created 2 groups, the first one
comprised of people considered controls (overall Malaise
score less or equal 7), the second one assumed to have
depression (Malaise score of 8 or over). The data were
afterward analysed with descriptive function, chi-square
and logistic regression. All analyses were performed using
SPSS 16.
Results.
Descriptive data. From a total of 11211 people there are
860 people with hypertension (7.7%) and 109 people with
diabetes (1%). From a total of 11211 people 1409 (12.6%)
have depression, and from this, 193 have developed
hypertension (high blood pressure) and 27 have developed
also diabetes, as it is shown in the figure below.

N=17

N=183
N=10

N=22

Figure 1. Distribution of hypertension, diabetes and

depression within the BCL-70 cohort

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

Data were first analysed with chi square. The
proportion of people with depression in the hypertension
group is higher 21.5% (183 out of 852) than the proportion
of depression in non-hypertensive group 11.9% (1225 out
of 10256), OR =2.017, CI=1.694-2.400, p=.001. The
proportion of people with depression in the diabetes group
is also higher 24.8% (27 out of 109) than the proportion
of depression in non-diabetes group 12.6 % (1382 out of
11003), OR=2.292, CI=1.478-3.554, p=.001.
Socio-economic status. It is virtually impossible
to evaluate the causality in a cross-sectional study like this
wave of the cohort. However, due to the fact that socioeconomic status may influence hypertension, diabetes and
depression, we analysed data to see this putative
influence. Our analysis showed that socio-economic
status did influence hypertension (Exp(B)=.879 CI=.797.969, p=.009), depression (Exp(B)=1.288, CI=1.1181.398, p=.001) but not diabetes (Exp(B)=1.081, CI=.8111.440, p=.597).
Moreover, there is also possible that people with
hypertension may be at risk for diabetes, and therefore we
analysed data (chi square) and indeed, people with
hypertension have a higher proportion of diabetes 3.7%
(32 out of 860) comparing with people with diabetes but
without hypertension .7% (77 out 10347), (OR 5.155, CI=
3.393-7.832, p=.001).
Because the possible influences between
variables are intricate (socio-economic status may
influence somatic illnesses but also depression, somatic
illnesses may increase depression risk and depression may
increase risk for somatic illnesses or decrease socioeconomic status and somatic illnesses may increase the
risk for the other somatic illness) we decided to analyse all
the data with logistic regression using depression as
dependent variable and hypertension and diabetes as
independent variable, while controlling for socioeconomic status. In this model depression risk is increased
by hypertension (Exp(B)=1.970, CI=1.579-2.458,
p=.001) and socio-economic status (Exp (B)=1.280,
CI=1.180-1.389, p=.001) but it is not increased by
diabetes (Exp (B)= 1.623, CI=.859-3.065, p=.135).
The above data seem to indicate that
hypertension is a risk factor for depression irrespective of
socio-economic status and diabetes. However, when we
analysed data only for people with diabetes but without
hypertension (chi square, without controlling for socioeconomic status because we already seen from previous
presented analyses that socio-economic status didn't
influence diabetes risk) it appeared that diabetes also
increased risk for depression, 21.1% from diabetes group
(17 out 77) and 11.9% (1208 out of 10179) from healthy
people, p<0.05 (see table below).
We looked for risk of hypertension but without
diabetes, while controlling for socio-economic status
(because socio-economic status did influence, as seen
from previous analyses hypertension and depression risk).
There is an increased risk for depression in pure
hypertension group (hypertension without diabetes),
p<0.05 (see table below). We are also looking in group
comprised of people with hypertension and diabetes while
controlling for socio-economic status and there again it is
an increased risk comparing with normal group, p<0.05
(see table below).
Data resulting from logistic regression are shown
in the table below.

High blood pressure

Diabetes
High blood pressure and
diabetes

Risk for depression in

BCS70
Exp (B)=2.016, CI=1.6132.521, p=.001
OR=1.860, CI=1.219-2.840,
p=.012
Exp(B)= 2.024, CI=1.6322.511, p=.001

Table1. Risk for depression in the chronic illness groups

formed in BCS70 cohort
Discussion
Our study supports that both diabetes and
hypertension increased depression risk, which replicates
results from previous studies (24,13,19,48,45,5456). We
would have preferred to have more objective data about
the presence chronic somatic illnesses at 30 years adults.
However, the only questions from the cohort which could
have offered more objective data Subject seen a doctor
for high Blood Pressure in past 12 months? and Subject
seen a doctor for diabetes in past 12 months? come with
huge numbers of missing questions (10914 for the first
one and 11178 for the second one leaving to few subjects
to be analysed 295 for hypertension and 78 for diabetes)
and no control group, therefore impossible to analysed.
The lack of more objective information regarding somatic
illnesses represents one important weakness of our study.
However, strength of our study is that it looked
into the association between the 2 illnesses, which is
rather rare in this kind of study. Results of our study
suggest that the risk is a little bit higher in co-morbid
group, but the augmentation of this risk is not quite
significant. Moreover, our study controlled the data for
socio-economic status, which is rare in this kind of study.
One more important observation is the fact that
people included in analysis are young, while other studies
of this kind looked in rather older population (49,57,58).
The young age of onset of chronic illness indicates that
they may be predisposed to more severe evolution. The
pervasive impact of depression on quality of life and its
potential negative effect on chronic disease management
warrant aggressive screening and clinical interventions
appropriate to each country's healthcare system in young
adults with diabetes and/or hypertension.
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Oct;68(10):9718.

CLINICAL CASE

RESISTANT PSYCHOSIS IN A PATIENT WITH

COEXISTING BETA-THALASSEMIA AND LATENT
TOXOPLASMOSIS
Alexandra Barbilian1, Dan Prelipceanu2
Abstract
We present the case of a 44 year-old caucasian male (V.B)
with a known psychiatric history of paranoid
schizophrenia, admitted to Prof. Dr. Al. Obregia
Clinical Hospital of Psychiatry during the months of MayJuly 2015 (67 days of hospitalization) for: compound and
complex auditory and visual hallucinations, paranoid
delusions, hallucinatory behavior, psychotic anxiety and
sleep disturbances, symptoms which had intensified in the
several months preceding admission despite following
adequate antipsychotic treatment. We present the
difficulties we encountered in treating his resistant
psychosis, the process of diagnosing his co-morbidities
(beta-thalassemia and latent Toxoplasma gondii
infection), a differential diagnosis of the intense positive
symptoms the patient presented and the implications of
toxoplasmosis in the evolution and treatment of a paranoid

schizophrenic patient.
Conclusion.
The scope of this paper was to show the importance of
performing a differential diagnosis and a thorough workup however certain we are of the patient's initial
presentation. We also wanted to emphasize the need for
studies that present more effective treatments of resistant
psychosis with fewer adverse reactions. The etiology of
schizophrenia presents a tremendous challenge for both
researchers and physicians, the latent toxoplasmosis
infection observed in high prevalence among
schizophrenic patients representing only a small part of
what remains to be discovered. Ultimately we must draw
attention to the importance of a multidisciplinary
approach to every case encountered.
Key words: resistant schizophrenia, Toxoplasma gondii,
Cooley's anemia, complex hallucinations

BACKGROUND
Treatment resistant schizophrenia represents a
challenge for any psychiatrist, especially if the patient
presents other co-morbidities like Cooley's anemia and
latent toxoplasmosis infection and a long course of
evolution as is the case presented in this article. The issue
of performing a well-documented differential diagnosis
remains equally important to a chronic patient with a long
psychiatric history and an apparently solid diagnosis of
paranoid schizophrenia as it is in the case of an acute de
novo psychotic episode. Research over the past years has
shown a high prevalence of Toxoplasmosis infection in
patients with neuropsychiatric symptoms and disorders,
most prominently in paranoid schizophrenia and mood
disorders, with influences on the course, severity,
treatment approach and response. [17,18,19,20,21]
We present the case of a 44 year-old caucasian
male (V.B) with a known psychiatric history of paranoid
schizophrenia, admitted to Prof. Dr. Al. Obregia Clinical
Hospital of Psychiatry during the months of May-July
2015 (67 days of hospitalization) for: compound and
complex auditory and visual hallucinations, paranoid
delusions, hallucinatory behavior, psychotic anxiety and
sleep disturbances, symptoms which had intensified in the
several months preceding admission despite following
treatment with clozapine 300mg/day and flupenthixol
decanoate depot 20mg/21days.
PAST PSYCHIATRIC HISTORY
The patient was first diagnosed with

schizophrenia in 1991 at 21 years old, shortly after

finishing national service. While in his military service, the
patient recalls presenting social withdrawal, flattened
affect and a decrease in volition, symptoms that caught the
attention of the unit's physician. Positive symptoms
(auditory and visual hallucinations and delusions) were
already present at his first psychiatric admission. In the
following years after receiving the diagnosis, he had other
3 admissions in the psychiatric ward, in 1996, '98 and '99,
after which his evolution was monitored in a non-hospital
setting. Over the years, the patient underwent treatment
with a wide range of antipsychotics (thioproperazine,
olanzapine, risperidone etc. ) but responded only partially,
both positive and negative symptoms remaining present.
In January 2015, while being treated with clozapine 500
mg/day, levomepromazine and alprazolam, he
experienced a loss of consciousness accompanied by
tonic-clonic seizures and post-critical confusion and was
admitted to the local neurology emergency unit. His
evolution was favorable under treatment with antiepileptic
agents and a decrease in clozapine dosage. He was
discharged with the diagnosis of G.40: localization-related
(focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset, not
intractable. Following this episode the patient's positive
symptoms worsened, the hallucinations becoming more
prominent accompanied by hallucinatory behavior which
eventually led to the admission to our ward.
The patient was never married, has no children,

Resident in Psychiatry, IX ward Prof Al. Obregia Academic Psychiatric Hosp., Bucharest, alex.barbilian@gmail.com
MD, PhD, Prof of Psychiatry, IX ward Prof Al. Obregia Academic Psychiatric Hosp., Bucharest.
Received May 4, 2016, Revised May12, 2016, Accepted May 16, 2016
2

55

Alexandra Barbilian, Dan Prelipceanu: Resistant Psychosis In A Patient With Coexisting Beta-thalassemia And Lantent
Toxoplasmosis
was never employed and keeps a very close relationship
with his sister who is also his caregiver. The patient doesn't
use nicotine or alcohol and has no relevant family
psychiatric history. From his family medical history we
know that his father dyed from metastatic lung cancer.
He denies having any allergies, is myopic and his medical
history involved two right humeral fractures and one right
scapular fracture, treated surgically in 2014 which the
patient recounts occurred when I was practicing boxing
and when I jumped off a tableI was training and an
uninvestigated chronic anemia which was treated with
iron supplements.
PSYCHIATRIC EXAMINATION performed on
19.05.2015: The patient appears to be his stated age, his
overall appearance is slightly disheveled although dressed
appropriately, wearing a suit and eye glasses, with
adequate hygiene and grooming. He exhibits slight
distress and anxiousness, seems uneasy but is cooperative.
Motor activity appears to be in normal limits although he
displays generalized jitteriness and restlessness. His
speech lacks in spontaneity, is slow and halting, quiet,
anxious and presents a slight stutter. There aren't
significant abnormalities in his thought process, his
answers are appropriate, most of the times to the point, at
times circumstantial. The patient is very polite, almost
manneristically so. The patient's thought content is
pathological, marked by persecutory and grandiose
delusions These people I see are out to get me, they're in
combat with me, they won't let me live. I have been
chosen by them, I'm the only one they can communicate
with. Perceptual disturbances are the prominent
symptoms in this patient. He describes ego-dystonic
compound hallucinations, both auditory: voices of people,
many of them, men and women, which commentate his
actions, talk to him and are most of the times imperative;
and visual hallucinations which are well-formed,
complex, include numerous people, animals and objects
there are thousands of them, men and women, a whole
world They are constantly looking at me. He also
describes scenic hallucinations I see the other world, of
those who are gone, I see where they are, what they're
doing, I see people right in this room, they're looking at
us. He perceives the audiovisual hallucinations as being
constant during the day while also interacting with the
other world and the people in it in his dreams. The patient
relates that the hallucinations had always been there, he
admits to perceiving them during the past years, but that
only in the last few months the voices had become
imperative My father is dead, he had glaucoma. They
urge me to take out my eye, my left eye and give it to him to
eat. In the last couple of months I have started to do what
they're asking, I'm trying to find a way to take it out, I don't
want to do it, but they're making me. He describes his
mood as being anxious I'm frightened about what the
voices are saying and making me do. The quality of his
affect is congruent with his mood and thought content, he
exhibits moderate anxiety and a restricted range of
emotions, both facial expression and voice lack
spontaneity. In contrast to the patient's cognitive abilities
(a score of 28 on MMSE with abstract reasoning within
normal ranges and a well-developed vocabulary) he has a
low level of functioning, an inability to hold a job or even
day-to-day chores I can't concentrate enough, I hear them
and I see them, I would love to read novels, but I can't, they
56

take over my mind. The patient's judgment is fair, he

understands the consequences of his actions and is able to
distinguish right from wrong, but fails to follow his
judgment and seems to be struggling with what the voices
command him to do: I know it will hurt, I know I
shouldn't do anything to hurt myself but I can't help but try
to do what they're asking in order for them to stop They
won't stop unless I do what they say and take out my eye.
The patient is able to test reality, but questions his own
insight and admits that I know I'm ill and that's why I see
and hear the things I do, but they are so real that I can't but
help to believe they're real and try to act on what they're
telling me.
PHYSICAL EXAMINATION revealed diaphoresis,
pallor and tachycardia (110 bpm regular) while the
neurological examination was unremarkable apart from a
generalized tremor.
LABORATORY AND IMAGING TESTS
We reviewed the laboratory findings taken
during his admission at the neurology unit in January
which revealed a microcytic/hypochromic anemia (RBC
5.82 million cells/mcL, HGB 11.5 g/dl, HCT 37.4%,
MCV 64.3fl, MCH 19.8pg) with low serum iron (53ug/dl)
- which the patient told had been treated with iron
supplements and leukocytosis (WBC 13.5 k/l)68.9ug/dl.
In the follow-up CBC and iron studies the RBC indices
were even lower ( HGB 9.9g/dl, HCT 30.9%, MCV 60.2fl,
MCH 19.3pg) with a serum iron level of 116ug/dl. A
hemoglobin electrophoresis test was done which
confirmed the diagnosis of beta-thalassemia minor (Hb
A2 5.7%, Hb A 93.6%, Hb F 0.7%). At the time of
admission to our ward the patient's WBC was 10.05 k/l
which we attributed to the long-term treatment with
clozapine.[12] CK, within normal range (42 UI). Native
CT was normal apart from a modest bi-frontal cortical
atrophy. EEG was unremarkable.
COURSE AND TREATMENT
The patient was admitted on 19th May. During
the first two days of admission we continued the patient's
treatment with clozapine 300mg/day to which we added
levomepromazine 50mg/day. The patient's hallucinations
were present, even heightened in their commanding effect
They tell me that my father's glaucoma extended to his
other eye, now I have to take out both of my eyes. Last
night, I couldn't sleep, they wouldn't let me, I tried to find a
gap, a breach so that I could take my eye out The patient
also accused nightmares with similar content to that of his
hallucinations. At the recommendation of the hospital's
GP the patient also started treatment with folic acid and
vitamins for the recently diagnosed beta-thalassemia.
Over the next days, haloperidol (15-20mg/day) and
trihexyphenidyl (4mg/day) the patient presented
geniospams- were added to his treatment regimen with no
effect on the patient's perceptual disturbances. During the
evening of 29th May, the emergency psychiatric unit was
called because the patient was intensely psychotic,
anxious, asking the medical staff to please, tie me up,
they're telling me to take out my eye, I'm afraid I'll hurt
myself or someone else, they're stalking me. At the
patient's repetitive requests he was physically restrained
for a total duration of an hour and administered 10mg
diazepam, 200mg Leponex and 25mg levomepromazine.
From the 2nd of June his treatment was changed to Leponex
300mg/day, amisulpride (500mg/day) and diazepam

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

20mg/day. After two weeks the dosage of amisulpride was
increased, first to 800mg/day and later to 1000mg/day
which was continued for almost two weeks. The patient's
complaints continued and so did his psychotic anxiety as
the hallucinations persisted. There were only a few days in
which he reported the voices were less imperative They
don't seem to tell me to take out my eye so much, but for
the whole duration of his hospitalization the positive
symptoms were resistant to treatment. With the signed
consent of the patient and his caregiver, on the 25th and 29th
of June he underwent two ECT sessions and on the 1st of
July was subjected to the third. Not only did the ECT have
no result on the patient's symptoms but the last ECT
session resulted in the patient suffering a left scapular
fracture for which he received orthopedic treatment and
pain relief medication. We had to stop the ECT treatment.
The patient continued having the same type of compound
audio-visual hallucinations which he described vividly: I
can see their world and our world at the same time, I can
also travel to their world, walk among them, infiltrate their
group. I can see them now, they're standing where they
always stand, thousands of them standing side by side on a
spiral, a descending tower in the form of a spiral, they are
watching us now. There are men, women, children, even
animals. The patient's positive symptoms also consisted
of delusions of grandeur and disorganized thought
content: I was a tree in Belarus in another life, a saint
planted me there. I'm still holding onto the branches lest
I'll fall. I fear I'll break my bones if I do. The voices are
talking about religion, I can see God with my mind's eye,
he is talking to the mortals. They tell me I'm not my
mother's son, that she was fertilized and I'm the son of
another woman, whom I've met in 2002 among the people
I see from the other dimension. On the 16th of July the
medical team decided to perform an indirect ELISA
Toxoplasma gondii antibody detection test which showed
a high level of IgG Toxoplasma antibodies (955.627
UI/ml). Over the rest of the hospitalization the patient
received clozapine 150mg/day, aripiprazole 30mg/day
and sodium valproate 1000mg/day with the positive
symptoms remaining stable and not so imperative I can
see and hear them like I've always had but they've stopped
telling me to take out my eye, they're talking among
themselves about religion, they say I've hidden from them
and they want revenge. We continued the treatment for
the rest of his hospitalization, the patient continued to
present the same perceptual disturbances but they
gradually became less commanding. He was discharged
stable with the following treatment: Leponex 150mg/day,
Abilify 30mg/day, Orfiril 1000mg/day and folic acid with
the recommendation of a parasitological exam. So far the
patient has followed the same prescribed treatment, didn't
follow-up with the parasitological evaluation and
continued exhibiting the same chronic psychotic features
but managing to keep the voices under control.
DISCUSSION: There are many notable features about
this case. Firstly we are dealing with a case of chronic
unremitting psychosis which remained resistant to
treatment with clozapine augmented by other
antipsychotic agents. One of our approaches after the
combination of haloperidol with clozapine proved to be
ineffective was to augment the patient's clozapine
treatment with amisulpride, an antipsychotic found to be
effective in patients with resistant psychosis.(5,6) The

association brought no significant benefit to our patient. A

second approach was ECT-augmented clozapine therapy.
A 2016 meta-analysis concluded that ECT-augmented
clozapine treatment may be both effective and a safe
alternative to treatment of resistant psychosis. The same
study suggests that a higher than usual number of ECT
treatments may be necessary.(1) Regrettably, we were
unable to perform more than three, due to the scapular
fracture the patient suffered during his last ECT treatment.
We attributed this event to the patient's beta-thalassemia
co-morbidity in which extra-medullary hematopoiesis,
bone frailty and consequent fractures are common
findings (2, 3,4) Moreover, an interesting aspect both
Cooley's anemia and schizophrenia seem to be genetically
linked with abnormalities found on chromosome 11.(16)
Yet another attempt was adding aripiprazole and sodium
valproate to the existing clozapine treatment taking into
account studies which suggest an improvement in
efficacy.(7,8,9,10) This choice of treatment combined
with the addition of sodium valproate to clozapine proved
to be somewhat successful in relieving the patient's
psychotic anxiety and diminishing, although faintly, the
intensity of his positive symptoms. The second prominent
feature of the case is the differential diagnosis of the
patient's chronic psychosis. What we found remarkable
was the high discrepancy between the patient's cognitive
level of functioning and the strength and vividness of his
perceptual disturbances which, together with the resistant
character of the exhibited pathology, at times made us
question the diagnosis. We considered other known causes
(13) of complex hallucinations as temporal epilepsy and
Lhermitte's peduncular hallucinosis. The diagnosis of
epilepsy was dismissed, the patient having a normal EEG
and no past history of epileptic seizures apart from the
above mentioned episode, occurred in January, considered
to be a side-effect of the chronic clozapine treatment
which is reported to increase the risk of seizures up to 6%,
with certain studies suggesting seizure prophylaxis in
patients undergoing treatment with clozapine following
the first seizure occurrence.(14,15) The diagnosis of
peduncular hallucinosis was discarded given the patient's
long psychiatric history and his recount of what seemed to
be the prodromal phase of his schizophrenia. Lastly, our
team was very intrigued at finding a clear confirmation of
a latent Toxoplasma gondii infection. Latent infection with
this parasite has, in recent years, been repeatedly
incriminated in the development of certain
neuropsychiatric symptoms such as anxiety, agitation,
mood fluctuations, paranoid psychosis and even specific
disorders such as schizophrenia and
depression.(17,18,19,20,21) Toxoplasmosis has a high
prevalence among schizophrenic patients, demonstrated
by over 40 studies, which also revealed a higher intensity
of positive symptoms in the infected patients.(17) Our
patient's powerful and detailed hallucinations were what
drew our attention and made us investigate a possible
Toxoplasma infection. A study (18) which included a
description of changes in the personality of infected
human subjects highlighted traits which our patient
exhibited: his excessive politeness, low confidence,
manierisms and lack of aggressiveness and impulsivity.
Another study emphasizes the impact that toxoplasmosis
co-morbidity has on the course of illness and response to
treatment. (21) As seen in our patient's case the study
57

Alexandra Barbilian, Dan Prelipceanu: Resistant Psychosis In A Patient With Coexisting Beta-thalassemia And Lantent
Toxoplasmosis
results show a 15x higher probability of a continuous
course of disease and a negative impact on treatment.(21)
Another confirmation of the importance the infection has
on the evolution of schizophrenia is that a successful
treatment approach to both co-existing morbidities was a
good response to treatment with valproic acid, which once
added to our patient's clozapine treatment was the only
measure that improved his evolution and allowed for a
discharge.
CONCLUSIONS
The scope of this article was to show the
importance of performing a differential diagnosis and a
thorough work-up however certain we are of the patient's
initial presentation. We also wanted to emphasize the need
for studies that present more effective treatments with less
adverse reactions of resistant psychosis. The etiology of
schizophrenia presents a tremendous challenge for both
researchers and physicians, the latent toxoplasmosis
infection observed in high prevalence among
schizophrenic patients representing only a small part of
what remains to be discovered. Ultimately we must draw
attention to the importance of a multidisciplinary
approach to every case encountered.
References
1.Lally J, Tully J, Robertson D, Stubbs B, Gaughran F, MacCabe JH.
Augmentation of clozapine with electroconvulsive therapy in treatment
resistant schizophrenia: A systematic review and meta-analysis.
Schizophr Res. 2016 Mar;171(1-3):215-24.
2.Vogiatzi MG, Macklin EA, Fung EB, Cheung AM, Vichinsky E,
Olivieri N et al. Bone disease in thalassemia: a frequent and still
unresolved problem. Miner Res. 2009 Mar;24(3):543-57.
3.Exarchou E, Politou C, Vretou E, Pasparakis D, Madessis G,
Caramerou A. et al. Fractures and epiphyseal deformities in betathalassemia. Clin Orthop Relat Res. 1984 Oct;(189):229-33.
4.Vogiatzi MG, Macklin EA, Fung EB, Vichinsky E, Olivieri N,
Kwiatkowski J et al. Prevalence of fractures among the Thalassemia
syndromes in North America. Bone. 2006 Apr;38(4):571-5.
5.Zink M, Knopf U, Henn FA, Thome J. Combination of clozapine and
amisulpride in treatment-resistant schizophrenia--case reports and
review of the literature. Pharmacopsychiatry. 2004 Jan;37(1):26-31.
6.Cook B, Hoogenboom G. Combined use of amisulpride and clozapine
for patients with treatment-resistant schizophrenia. Australas Psychiatry.

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2004 Mar;12(1):74-6.
7.Srisurapanont M, Suttajit S, Maneeton N, Maneeton B. Efficacy and
safety of aripiprazole augmentation of clozapine in schizophrenia: a
systematic review and meta-analysis of randomized-controlled trials. J
Psychiatr Res. 2015 Mar;62:38-47.
8.Mossaheb N, Kaufmann RM. Role of aripiprazole in treatmentresistant schizophrenia. Neuropsychiatr Dis Treat. 2012;8:235-44.
9.Mossaheb N, Spindelegger C, Asenbaum S, Fischer P, Barnas C.
Favourable results in treatment-resistant schizophrenic patients under
combination of aripiprazole with clozapine. World J Biol Psychiatry.
2010 Mar;11(2 Pt 2):502-5.
10.Hosk L, Libiger J. Antiepileptic drugs in schizophrenia: a review.
Eur Psychiatry. 2002 Nov;17(7):371-8.
11.Moriigo A, Martin J, Gonzalez S, Mateo I. Treatment of resistant
schizophrenia with valproate and neuroleptic drugs. Hillside J Clin
Psychiatry. 1989;11(2):199-207.
12.Sopko MA, Caley CF. Chronic leukocytosis associated with
clozapine treatment.Clin Schizophr Relat Psychoses. 2010 Jul;4(2):1414.
13.Manford M, Andermann F. Complex visual hallucinations. Clinical
and neurobiological insights. Brain. 1998 Oct;121 ( Pt 10):1819-40.
14.Grover S, Hazari N, Chakrabarti S, Avasthi A. Association of
Clozapine with Seizures: A Brief Report Involving 222 Patients
Prescribed Clozapine. East Asian Arch Psychiatry. 2015 Jun;25(2):73-8.
15.Williams AM, Park SH. Seizure associated with clozapine: incidence,
etiology, and management. CNS Drugs. 2015 Feb;29(2):101-11.
16.Borras L, Huguelet P. Schizophrenia and beta-thalassemia: a genetic
link?Psychiatry Res. 2008 Mar 15;158(2):260-1.
17.Flegr, J. Influence of latent Toxoplasma infection on human
personality, physiology and morphology: pros and cons of the
Toxoplasma-human model in studying the manipulation hypothesis.J
Exp Biol. 2013 Jan 1;216(Pt 1):127-33.
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Ducasse D, Boulenger JP. [Toxoplasma gondii: a potential role in the
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19.Henriquez SA, Brett R, Alexander J, Pratt J, Roberts CW.
Neuropsychiatric disease and Toxoplasma gondii infection.
Neuroimmunomodulation. 2009;16(2):122-33.
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Association between latent toxoplasmosis and clinical course of
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1;62. pii: 2015.015.

***

THE HISTORY OF ROMANIAN PSYCHIATRY

DOSARUL DE SECURITATE AL PSIHIATRULUI

DAN ARTHUR, O POSIBIL DOCU-DRAM
Mihai Ardelean*
*

Mihai Ardelean este medic primar psihiatru, dr. n medicin, liceniat n istorie al Facutii de Istorie a Universitii Babe - Bolyai' din Cluj Napoca i
lucreaz la Ambulatorul de Specialitate al Spitalului Judeean din Tg. Mure.

Iat cum, odat cu trecerea timpului, lucrurile

intr n uitare, chiar i n istoria politic a psihiatriei; se
atenueaz asprimea evalurii faptelor, ba am putea spune
c un fel de desuetudine acoper semnificaia, altdat
relevant, grea de nelesuri, a formrii psihiatrului prin
cunoaterea omului att n normalitate, ct i n suferin.
n afar de suferina dat de boal se citea de viitorul medic
specialist i suferina nespus, pricinuit unora, deloc
puini, de ctre regimul politic ce le era dat s-l rabde. Asta
e n firea lucrurilor, am putea spune, dar trebuie s ne
ntoarcem mereu la repere, mai ales atunci cnd acestea
constituie reflexiile morale ale unui timp i semnaleaz
condiia moral sau imoral a unei societi. Mai cu seam,
dac vrem s scpm de perimare lucruri de via i de
moarte, ncorsetri de liberti, mutilri de personalitate;
tocmai ale acelor profesioniti menii s pstreze integr
personalitatea altora. Indiferenei fa de ce nu este actual,
trebuie s-i rspundem c rul ca i binele nu pot fi uitate.
n cutarea unor adevruri, de ce nu am regsi pentru
trecutul psihiatriei romneti polaritatea ru - bine,
dumnos - prietenos, ntr-un domeniu prezentat, la
vremea lui, ca un bloc monolitic, i anume, domeniul
activitii temutei i, pn la urm, aiuritoarei Securiti?
Domeniu care ngloba la modul totalitar i psihiatria.
Aa am ajuns s parcurg istoria unei nscenri de
urmrire informativ, de verificare, care s-a desfurat
ntr-un loc potrivit mai degrab unei reconstituiri istorice.
Acest loc fiind pstrat i readus n mentalul colectiv
romnesc drept castelul regal de la Svrin. Pe traseul
evenimentelor remarcabile ale castelului, ntre reedin
regal a Regelui Mihai i reedin trectoare, la ceas de
tain, a preedinilor proletari Tito i Ceauescu, i-a fost
urzit acestui loc s fie i un aezmnt de asisten
psihiatric pentru nevrotici.
Reconstituit din
documente de la CNSAS, Sanatoriul devine, dac vrem, un
depozitar al unor secvene att din istoria psihiatriei, ct i
din istoria Securitii. Evenimentele surprinse n rapoarte
i note informative au fost i ele parte dintr-o lume
comunist, corupt de practici i limbaje, intenionat
msluitoare a adevrului; adevrul acesta este redat mai
crud n documente dect dac ar fi fost povestit i
repovestit prin simpla inversare a cititului pe dos.
S ne edificm printr-o privire asupra unui pasaj
de realitate dintr-un mediu psihiatric, unde exista, ca peste
tot, o mic lume, ce s-a constituit ntr-un loc de
supraveghere a Securitii. Personajul urmrit a fost o

persoan care ntrunea datele urmririi, avea tangene cu

lumea occidental, era un profesionist recunoscut, era ntro relaionare cu lumea intern i extern, strnea vaszic
interesul i se constituia ntr-un subiect de urmrit, demn
de scenariile organelor. Este vorba de medicul psihiatru
Arthur Iancu Vasile Dan.
Unul din atributele Securitii era s nscoceasc
motive de urmrire i pentru persoanele indezirabile din
punct de vedere politic bnuite c ar putea pune n pericol
sigurana regimului. Lista persoanelor supuse urmririi
informative speciale, aflat n continuarea celor ce
trebuiau luate n supraveghere informativ general
constituia baza de lucru, n care se regseau i ceteni
romni care au legturi cu caracter dumnos cu
cetenii altor state ce se afl temporar n ara noastr,
asupra crora exist materiale c au desfurat sau
desfoar activitate de spionaj1. Cel mai temut spionaj,
primul ca indicativ n raportare, era spionajul american:
Pe indicativul: 212, se vor raporta problemele spionajului
american2. Dup alte probleme, precum problema cu
violarea de ctre avioanele rilor capitaliste a spaiului
aerian al R.P.R, lansarea de parautiti, lansarea din
avioane manifeste etc, problemele elementelor fugite n
rile capitaliste urmau s fie raportate pe indicative
numerice cresctoare problemele spionajului altor ri,
regimuri politice i poliii politice, ntr-o ordine a
importanei acordate: problemele spionajului iugoslav,
englez, francez, italian, hortyst, gestapoul, austriac,
Israel, grec, turc i ale rilor din Orientul Apropiat,
elveian, suedez3.
Am prezentat subiectul spionajului, att de
motivant pentru Securitate, deoarece ntr-unul din
dosarele studiate, cel al medicului psihiatru Arthur Iancu
Vasile Dan4 , am descoperit cum acesta a fost urmrit
informativ, pe baza unei suspiciuni inventate de spionaj, n
favoarea americanilor. Fostul asistent al Clinicii de
Psihiatrie din Cluj, liceniat n acelai an, 1948, al
facultilor de filosofie i medicin din acelai ora, cu
prietenii intelectuale printre membrii Cercului Literar
fondat la Sibiu, n perioada de refugiu al universitii
clujene Ferdinand I, devine, n acest dosar, suspectul
numrul unu al localitii Svrin i este supus unei
urmriri draconice, de o detaliere de-a dreptul rizibil. Iat
cum este prezentat el, doctorul, i activitatea lui n
hotrrea pentru nchiderea dosarului de verificare nr.
2894 din 25.II. 1963.

1
Bartos Zoltn (editor), Ministerul Afacerilor Interne/Ministerul Securitii Statului/Consiliul Securitii Statului, Direcia Regional Mure (19511952)/Direcia Regional Autonom Maghiar (1952-1960)/Direcia Regional Mure-Autonom Maghiar (1960-1968)/Inspectoratul de Securitate
al Judeului Mure (1968), Documente, Ed. Risoprint, Cluj-Napoca, 2012, p. 739-740.
2
Ibidem, p. 235
3
Ibidem.
4
Arhiva C.N.S.A.S., Dosar I. 259025, vol. 1, vol. 2.
Primit 4.04.2016, Revizuit 14.04.2016, Acceptat 22.04.2016

59

Mihai Ardelean : Dosarul de securitate al psihiatrului Dan Arthur, o posibil docu-dram

MINISTERUL AFACERILOR INTERNE

DIRECIA REGIONALA BANAT
BIROUL RAIONAL LIPOVA
STRICT SECRET
SE APROB:
EFUL DIRECIEI REGIONALE
LT. COLONEL
STESKAL W.
HOTRRE
pentru nchiderea dosarului de verificare nr. 2894 privind
pe numitul dr. DAN ARTHUR, bnuit c desfoar
activitate de spionaj n favoarea SUA.
1 Dosarul s-a deschis la 18.I.1962 i a durat pn la
25.II.1963 / un an i o lun/. n aceasta
aciune de verificare a fost folosit agentura.
I. DATE DE IDENTIFICARE:
DAN ARTHUR s-a nscut la data de 10 august
1923, n oraul Tg.-Mure, fiul lui Arthur si Georgeta, de
naionalitate i cetenie romn, studii posed facultatea
de medicin, de profesie medic psihiatru, lucreaz la
sanatoriul de NEVROZE din Svrin n funcia de
director, n trecut nu a fcut parte din nicio organizaie
politic, n prezent nencadrat din punct de vedere politic.
Originea social burghez, este fiu de general provenit din
armata burghez.
II. CONINUTUL MATERIALELOR
COMPROMITOARE:
1. Temeiul deschiderii dosarului:
Organele noastre au deinut materiale din care a rezultat c
acesta n funcia de director al sanatoriului Svrin, c n
timp ce consulta pe unii bolnavi care dein funcie de
rspundere pe linie de partid i de stat ar strecura unele
ntrebri referitoare la munca lor culegnd astfel diferite
informaii.
Au existat de asemeni suspiciuni c sus-numitul n timp ce
aplic tratamente cu ocuri electrice la diferii bolnavi
acetia i pierd complet cunotina i rspund la orice
ntrebare.
2. Ce trebuie s stabileasc verificarea:
Stabilirea i verificarea ce fel de date culege
susnumitul de la bolnavii internai n sanatoriu i cum face
el acestea. Identificarea si verificarea legturilor
susnumitului i n ce constau aceste legturi.
3. Ce s-a stabilit i ce dovezi sunt:
n aciunea de verificare a fost recrutat agentul
Popescu Alexandru cu numele real de FULEA IOAN.
Acest agent a fost legtura apropiat a Dr. DAN
ARTHUR, lucru ce a fcut ca prin acest agent s
clarificm nc de la nceput unele probleme importante.
Astfel, agentul nostru a lmurit problemele n care Dr. Dan
prezenta suspiciuni c culege informaii de la unii bolnavi,
n urma tratamentului ce-l aplic acestora cu ocuri
electrice, lucru ce nu se confirm. n nota sa informativ
dat n ziua de 24 mai 1962 acesta arat ocurile electrice
sunt fcute de ctre unul dintre medici i de cele mai multe
ori de FULEA IOAN (agentul nostru) n cabinetul

directorului fiind de fa sora ef i restul personalului

medical care sunt necesare efecturii acestui tratament, n
orice caz ocul nu poate fi fcut de o singur persoan cu
att mai mult de Dr. DAN ARTHUR, care este infirm.
Acest material a fost confirmat i de Dr. Hangan
Octavian, agentul nostru cu numele conspirativ de
Alexandru , care a fost recrutat la data de 13 I 1963 i a
fost dirijat pe lng Dr. DAN ARTHUR.
La data de 13 I 1963, pe lng Dr. DAN ARTHUR
a mai fost recrutat un alt agent medic, psihiatru cu numele
de Alexandru5. Acest agent se bucur mult de
ncrederea obiectivului, este un medic foarte bine pregtit
n specialitatea de psihiatrie, lucru ce face s fie apreciat
foarte mult de dr. DAN, i acesta s-i ncredineze multe
sarcini importante, att pe linie profesional, ct i pe linie
administrativ.
Prin agentul Alexandru s-au lmurit multe
aspecte legate de activitatea dr. DAN. Astfel, agentul are
informaia c dr. DAN nu are niciun fel de manifestare
dumnoas fa de regimul nostru. De asemeni, agentul
nostru a lmurit problema dac Dr. DAN mai folosete
morfin sau nu, astfel, ne arat n nota informativ din 14
II 1963 Cunosc problema intoxicrii cu morfin, lucrnd
cu muli morfinomani i pot afirma cu certitudine c dr.
DAN nu consum morfin. n primul rnd n tot sanatoriul
s-a interzis s existe fiole cu morfin, pe de-o parte toate
medicamentele le controlez personal. Pe de alt parte
starea sntii n care se afl nu poate s suporte sau s ia
morfin, ntruct aceasta ar fi fatal pentru dnsul. Starea
de infirmitate nu-i permite atunci cnd are nevoie de
morfin s caute. Iar dnsul fiind un morfinoman care are
nevoie de 20-30 de fiole, odat s-ar putea constata foarte
uor fiziologic i fizionomic, morfinomanii au o anumit
fa special, ceea ce la el nu se constat. Deci, certamente
pot afirma c dr. DAN nu mai consum morfin.
Tot prin agentul Alexandru s-a lmurit aspectul
legturii Dr. DAN ARTHUR cu MANEA VIORICA i
sora OVEZIA, precum i alte femei din cadrul
sanatoriului. Aceste legturi sunt numai legturi de
servici[u], dar modul cosmopolit n care acesta se poart n
general fa de femei i faptul c acesta este infirm las
impresia c acesta s-ar deda la inversiuni sexuale fa de
aceste femei
Din materialul furnizat de agenii notri nu
rezult faptul c dr. DAN ar desfura activitate de
spionaj. Acesta are unele manifestri impulsive fa de
subalterni i modul su de comportare n toate ocaziile,
acesta d dovad c este un cosmopolit, un specialist
format n coala veche i se acomodeaz greu noilor relaii
de munc i trai din noua noastr ornduire de stat.
Aceasta este oglindit i prin faptul c nici pn la aceast
dat nu folosete fa de nimeni cuvntul tovar i nici nu
accept s i se spun tovar.
ntruct nu se confirm faptul c numitul DAN
ARTHUR n activitatea sa de director de sanatoriu [la]
Svrin i specialist n psihiatrie, prin diferite procedee
de tratament ce le ntrebuineaz i le aplic bolnavilor ar
culege informaii ce ar constitui date cu caracter secret,

5
ntr-o alt not informativ, din 14 II 1963, se aduc lmuriri asupra electroocurilor ca metod de tratament: Sursa [Alexandru] v informeaz c
aa numitul tratament de abrazare sau n mod laic cum se spune de blegeal. Acest tratament este unul din tratamentele importante i majore care
se aplic la orice spital de neuropsihiatrie. Indicaiile la care se aplic acest tratament sunt bolile mintale care prezint turburri de comportament, de
conduit i turburri de caracter (cade ntr-o beie, reclamanii imorali etc.). (Arhiva C.N.S.A.S., Dosar I. 259025, vol. 1, f. 16.).

60

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

precum i faptul c legturile soiei sunt numai legturi de
ordin sentimental, PROPUNEM nchiderea dosarului de
verificare [a] numitului DAN ARTHUR, clasarea
materialului la secia C, iar susnumitul s fie luat n
evidena operativ activ.
EFUL BIROULUI RAIONAL
LOCIITOR EF
B I R O U M A I O R D E S E C U R I TAT E
MAIOR DE SECURITATE
BEJENARU N. MITROFAN V.6
Fosta reedin regal de la Svrin i
schimbase destinaia n folosul unei categorii de pacieni,
aa-ziii nevrotici, presupui c sunt contieni de
problemele lor de sntate, i, prin urmare, cooperani la
tratament. Ei beneficiau pe parcursul ederii lor la castel
de ceea ce se numea o cur sanatorial, n condiii de
confort sporit, n scopul refacerii capacitii de munc,
aa dup cum prevedeau cerinele propagandistice ale
partidului unic. Dar, dup criteriile de selecie i trimitere
de la unitile sanitare de specialitate din toat ara, nu
orice fel de nevrotici ajungeau ntr-o astfel de instituie,
ci doar tovari care dein munci de rspundere, de la
diferite instituii sau ntreprinderi 7 . Aceast
microsocietate a unei aezri psihiatrice purta denumirea
de Sanatoriul Republican de Nevroze din Svrin.
ntr-o not informativ8 a pacientului Stan Aurel
(nume conspirativ), din Regiunea
Maramure,
colaborator al Securitii aflat n misiune de refacere
psihic, regsim o precizare referitoare la rangul ce i
fusese acordat Sanatoriului n ierarhia valorilor sociale
promovate de noua clas diriguitoare. n aceast not
aflm i explicaiile ideologice ale dreptului la un
tratament exclusivist, pentru persoanele privilegiate de
Partid, n mod contrar principiilor unui societi
egalitare, aa cum erau ele enunate ntr-un stat comunist.
Afirmaiile fidelilor regimului asupra unor subiecte
sociale, precum cel al recuperrii sntii mintale, nu
reueau s treac peste condiionarea la o logic
Orwellian: Sanatoriul Svrin, dup cum este
cunoscut, este un centru pe plan naional n problema
tratamentului bolnavilor de nevroz. Aci sunt tratai
activiti de frunte, ilegaliti, organe M.A.I. etc, elemente
de elit ale regimului care s-au sacrificat pentru eliberarea
Patriei, pentru construcia socialismului.
Notele informative erau n mare parte
superpozabile unor delaiuni. Fr comentarii, vom reda
textul plin de agramatisme al unei astfel de note, locul
depunerii acesteia, postul de miliie Svrin9, fiind
posibil i mediul cel mai favorabil pentru desctuarea
inspiraiei delatorului.
NOT INFORMATIV
27. 07. 1962
V informm c n ultimul timp Dr. DAN
ARTHUR are o comportare necorespunztoare, n sensul
c folosete o serie de expresii neadecvate i pornografice
n relaiile sale cu personalul medical, precum i cu unii
bolnavi, unor surori le adreseaz asemenea expresii.
n timpul internrii bolnavului Sndulescu Petru,
care a solicitat prelungirea sanatorizrii, Dr. DAN i care
iniial i-a aprobat-o, urmnd ca peste dou zile s anuleze

prelungirea i s-i fac ieirea. n aceast situaie bolnavul

s-a prezentat la Dr. DAN i a cerut s-l prelungeasc, iar
Dr. DAN n-a acceptat, iar [la] insistena bolnavului i-a
adresat cuvinte pornografice i i s-a fcut ieirea.
Asupra relaiilor dintre Dr. DAN ARTHUR i
bibliotecar, sursa v informeaz urmtoarele: zilnic att
nainte de mas, ct i dup mas, bibliotecara MANEA
VICTORIA se afl la Dr. Dan, uneori discutnd mai intim,
iar printre angajaii sanatoriului se discut c ntre Dr.
DAN i bibliotecar ar exista relaii de inversiune sexual
(Dr. DAN fiind impotent), fapt ce dovedete i unele
avantaje ce i le creeaz n servici[u] Dr. DAN bibliotecarei
n sensul c a fost premiat atunci cnd avea i imputaia,
iar n ultimul timp a intenionat s-i dea i munc
nenormat.
ntre Dr. DAN i Dr. Hangan exist legturi
foarte apropiate. Astfel, la intervenia Dr. DAN a fost adus
la Svrin Dr. Hangan, iar n scurt timp a fost numit de Dr.
DAN director adjunct.
Odat cu venirea Dr. Hangan Dr. DAN a iniiat
tratamentul numit psihodram, numai cu Dr. Hangan i
ntmpltor cu dr. BABE, fiind inut n mod secret acest
tratament fa de restul medicilor.
ss. Popescu Alexandru10
Polaritilor circulante n epoca luptei de clas, n
camerele de anchet ale Securitii, li se aduga perechea
ofierului ru, btu, succedat de ofierul bun. Cel care
prea mai agreabil oferea igri i ndemnuri la nonrezisten. n dosarul de verificare nr. 2894 privind pe
numitul dr. DAN ARTHUR, acestei perechi antagoniste
de ofieri i s-ar putea suprapune perechea medicilor
informatori, dintre care unul ru intenionat, altul bine
intenionat. Primul ca vechime pe statele de funciune ale
Securitii, agentul nostru Popescu Alexandru, alias dr.
Ioan Fulea, l ncondeia pe omul - obiectiv, dr. Arthur
Dan. Cellalt agent, Alexandru, alias dr. Octavian
Hangan, nou recrutat, dar tot al nostru, l spla de
pcate pe colegul i maestrul Dan, aflat n siajul dosarului
de urmrire. Deosebirea dintre cele dou tipuri de
prelucrare n tandem, ar fi c n grupul informatorilor,
actanii nu tiau unul de cellalt, nu-i bnuiau nici
inteniile i nici stilul n care i scriau notele informative.
Nota pe care o d agentul Alexandru, informatorul bine
intenionat, nu are datele incriminrii. Agentul ncearc
s-l justifice pe bnuit, are un ton oarecum neutru, aa
nct psihiatrul Dan Arthur nu apare aici periculos pentru
regim, ci destul de inofensiv.
MAI Biroul Raional Lipova
Problema: spionaj american
Sursa: Alexandru
Data: 26.II.1963
copie
Primete: Maior Mitrofan V
2 exemplare
Locul: sanatoriul Svrin
NOT INFORMATIV
Sursa v informeaz referitor la dr. DAN
ARTHUR directorul sanatoriului de nevroze din Svrin.
Profesional: Din punct de vedere profesional este
foarte bine pregtit i informat, cunoate toate curentele

Arhiva C.N.S.A.S., Dosar I. 259025, vol 1, f. 68-71.

Ibidem, f. 12.
8
Ibidem, f. 44.
9
Ibidem, f. 36.
10
Ibidem.
7

61

Mihai Ardelean : Dosarul de securitate al psihiatrului Dan Arthur, o posibil docu-dram

care sunt n psihiatrie att cele occidentale ct i cele

moderne sovietice. n concepia sa asupra vindecrii unei
boli psiho-[somatice] dr. DAN se axeaz n special spre
latura clinic a bolii, adic asupra simptomelor pe care le
reprezint un bolnav.
n momentul de fa, dnsul nu interpreteaz o
boal mintal n concepia unei coli sau a unui curent fie
reacionar, fie modern progresist, dei se pare c nainte a
fost adeptul concepiei n psihiatrie a lui JUNG i nu a [lui]
FREUD, JUNG fiind unul din elevii lui FREUD care i-a
criticat [maestrul] i nu a fost de acord cu FREUD. n
nenumratele discuii purtate mpreun pe teme
profesionale a manifestat un interes asupra concepiei
nerviste a lui I. P. PAVLOV asupra nevrozelor, astfel ntr-o
lucrare [pe] care am trimis-o la Revista de Neurologie i
Psihiatrie, lucrare tiinific efectuat mpreun, ne-am
bazat n redactarea ei tocmai pe concepia lui Pavlov
asupra nevrozelor.
Greeala care se efectueaz n general n psihiatrie este
tocmai ceea ce am numit la nceput interpretarea, ntruct
concepiile occidentale merg i sociolizeaz [sic!] pe de o
parte, iar pe de alt parte ajung la concluzii filozofice, care
de multe ori sunt justificrile i legile concepiei idealiste
reacionare. Or dr. DAN se ferete s fac o interpretare,
de multe ori justificndu-se n felul urmtor, eu sunt un om
care am deraiat, nu am mult de trit, ce rost ar avea s m
apuc s problematizez sau s teoretizez problemele
majore ale psihiatriei, sunt un ratat.
Apartenena sa politic: Discutnd de multe ori
asupra multor probleme internaionale, ct i de[spre]
concepii asupra sistemelor socialiste pot afirma cu
certitudine c este un apolitic. Niciodat nu a fcut
politic. mi comunic c singura activitate obteasc [pe]
care a fcut-o n ntreaga sa existen a fost [de] secretar
ARLUS, prin 1946, a oraului Cluj. Nu cunosc perioada
pn la accident, ce a fcut [la] Trnveni, Galai, dar pot
spune de situaia actual.
Citete n mod curent presa, Scnteia i
lHumanit organul C.C. Francez, astfel c este informat
asupra situaiei internaionale ntruct discuiile purtate cu
dnsul, judec n modul ct se poate de corect situaiile sau
conflictele internaionale. Dar se simte c nu este convins
ntotdeauna, dat fiind complexele sale de infirmitate i
prezena continu a morii, o face sec, n gol. Nu am
observat idei reacionare ca s le vehiculeze, este de acord
cu regimul nostru l respect nu ar fi n stare s fac acte
importante.
Nu ascult dect foarte rar radioul, i atunci
numai muzic, deoarece refuz categoric s asculte tiri
ntruct acest lucru l pune n contact cu lumea de afar i
i accentueaz i mai mult starea sa de infirm, c este
condamnat definitiv s stea n crucior i s nu poat
umbla. Nici n camera n care doarme nu are radio. Ascult
muzic, care constituie de multe ori singurul mijloc de a se
calma.
Nu am auzit s adreseze cuvinte injurioase sau s
desconsidere Partidul nostru. De multe ori cnd RA
IOSIF, preedintele de sindicat, svrete greeli
principale i uneori, privind calitatea unui membru de
partid, se refer la mita [pe] care a primit-o RA IOSIF ca
11

Ibidem,f. 14-15.

62

s angajeze o femeie. mi spunea, dac un membru de

partid este permis s fac acest lucru[?] Tot el ddea
rspuns. tii, eu ntotdeauna mi-am format o prere despre
un membru de partid ca un om integrant [sic!], cinstit,
loial.
Pot afirma c DAN ARTHUR este un om care
respect linia partidului, cunoate materialismul dialectic,
dar dat fiind infirmitatea n care se afl nu are pasiunea i
convingerea necesar pe de o parte, iar pe de alt parte,
fiind i n timpul ct a fost sntos era un apolitic, situaia,
astfel, convingerile sale ideologice fiind de o asemenea
natur.ss. Alexandru
OBSERVAII : Materialul se refer la dr. DAN lucrat de
organele noastre n dosar de verificare fiind suspect c
desfoar activitate de spionaj n favoarea SUA.
SARCINI: Agentul a fost instruit s discute cu obiectivul
despre evenimentele politice actuale i despre modul cum
vede dr. DAN aciunea unor elemente din occident n
problema dezarmrii i a politicii de rzboi dus de SUA i
alte ri capitaliste.
ss. Maior Mitrofan V.11
Personajul supravegheat, dr. Dan Arthur, aa cum am
vzut i ntr-un document anterior, n care i se nega la
finalul filajului activitatea de spionaj, a fost o persoan
care ntrunea datele politice ale oricrei urmriri de tip
comunisto-securistic.
Dincolo de materialul sterp, lipsit de coninut al
notelor informative, al motivaiilor trase de pr, dincolo de
observaiile unor angajai ai Securitii, de informaia
oficial ca s spunem aa, exist o mic lume n aceast
dezbatere, numit Castelul de la Svrin, unde zeul
locului este chiar doctorul Dan Arthur. Prinul
nencoronat al psihiatriei romneti cum era numit, nu se
mai tie de cine, printre psihiatrii timpului. i toate
acestea, att pentru personalitatea lui, pentru autoritatea
dat de funcia de director, perceput nu la modul
birocratic, ci mai mult ca aceea a unui ef de coal de
psihiatrie. Era un animator nu numai al locului, dar i al
breslei psihoterapeuilor, care n acele vremuri nu se
bucura de o recunoatere oficial. Terapeuii prin cuvnt
se formau pe ascuns, sub conducerea unui maestru,
precum era psihiatrul Dan Arthur, bibliografia fiind
procurat tot de acesta, pe ci mai mult sau mai puin
formale. Profesorul Mircea Lzrescu, ntr-o discuie pe
acest subiect, mi-a relatat c se internau la Sanatoriu i
cteva bibliotecare de la Biblioteca Central Universitar
din Bucureti, atunci cnd acestea oboseau sau nu mai
fceau fa la grijile cotidiene. Le tihnea locul linitit,
aerul i peisajul din lunca Mureului, la care contribuia,
pentru refacere, i purtarea atent, nelegtoare a
personalului. Biblioteca Central era una dintre puinele
instituii academice care mai primea publicaii din
strintate, i astfel ntre Bucureti i Svrin se stabilise
un curierat de cri i reviste, de ultim or din Occident.
Bibliotecarele externate din Sanatoriu duceau ce se citise
deja i solicitrile de nouti, iar cele care veneau la odihn
aduceau ultimele apariii ajunse n ar.
Prin urmare, vorbim aici i de activitile de formare
profesional ale maestrului n arta vindecrii, de
traducerea de ctre acesta a unor opusuri de psihoterapie,

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

de cri i articole de psihiatrie, sau de activiti de alt
natur, cu un coninut cultural, psihosocial. Pentru
Securitate, la Svrin, totul se nate se pare din aproape
nimic. Observm c dr. Dan Arthur avea muli amici
importani socialmente, dobndii i prin nsui exerciiul
profesiei, adic pacieni de-ai lui. ntre aceti pacieni
existau, firete, i politruci limitai, existau oportuniti,
ruvoitori, santinele ale intransigenei proletare. n
decriptarea aciunilor Securitii, exist un fel de story de
salon, n care totul ar fi pornit de la un incident minor.
Un bolnav cu funcie, n urbea de unde fusese trimis la
tratament, isc un conflict la buctrie; este, ca orice
tovar cu rspunderi pe linie de partid si de stat, un
individ care supraliciteaz, care vrea s demonstreze c
exist, i de aici ncepe practic subiectul dosarului. Acest
binevoitor sesizeaz Centrul c exist un caz ce
trebuie urmrit la Svrin, ce-l vizeaz tocmai pe
directorul Sanatoriului. Sigur c Svrinul exercita o
atracie deosebit din perspectiva alctuirii unui dosar de
urmrire, avnd n vedere c implica n mentalul colectiv
amintiri regale grefate pe o realitate ce funciona sub
forma unui Sanatoriu de importan republican12 .
Avnd aceste date, se organizeaz filiera urmririi. Astfel,
conform planului de msuri din 16.06. 196213,
agentul Popescu Alexandru va fi instruit n continuare ca
prin natura serviciului s fie atent i s observe felul cum
face Dan examenul psihiatric, respectiv la ce categorie de
elemente acord importan, respectiv care dup
profesiile i activitatea lor sunt n posesia unor probleme
cu caracter secret14. Mai departe, agentul trebuia s
informeze n ce condiii dr. Arthur Dan consult pacienii,
singur sau n prezena altor persoane, ce discut cu acetia,
de cine este vizitat, unde se deplaseaz i cu ce scop.
Din grupul urmritorilor face parte i agentul
Munteanu, prin care Securitatea avea ca scop s afle
care este atitudinea doctorului fa de regim, interesul fa
de munc i de cine este vizitat. Aflm din acelai plan de
msuri c agentul a fost coleg de liceu cu medicul Dan i
astfel va putea discuta cu el despre colegii lor ce mai tie
despre acetia, dac s-a mai ntlnit cu cineva15.
Sursa Munteanu Gheorghe este foarte activ.
Conform notei informative, din 3.05. 1962, sursa a
ncercat s se apropie de el (Arthur Dan n.n.) amintindu-i
de anii din liceu, dar acesta se arat prost dispus, iar cnd
sursa a plecat i-a spus c o s mai treac pe la el i o s mai
stea de vorb. Acesta nu l-a refuzat i i-a spus c s treac
dup mas cnd nu e aa ocupat i cnd va putea sta mai
mult de vorb i l va servi cu ce are nevoie16.
Acelai agent Munteanu abordeaz
informativ i alte persoane din Sanatoriu, n intenia de
a-l mulumi pe lt. Bivolu D. (un nume predestinat n.n.),
ofierul su de legtur. Reproducem integral textul notei
pentru modul n care informaiile adunate despre Dan
Arthur gliseaz de la uet la brf, de-a lungul unei
relatri n care admiraia fa de puterile lui vindectoare
se regsete alturi de presupuneri deucheate.

NOT INFORMATIV
9. 06. 1962
n ziua de 9 mai 1962, sursa a stat de vorb la
Svrin cu Dr. LOHAN TRAIAN, printre altele a discutat
despre viaa acestuia. Sursa l-a ntrebat ce a fcut n cei
cinci ani de la terminarea liceului pn la nscrierea n
facultate, iar LOHAN i-a spus c n cei cinci ani a fost de
toate. nti femeie de serviciu, infirmier, oficiant sanitar
i apoi tehnician radiolog, adic a fost ncadrat pe aceste
posturi.
ntrebat cum se mpac cu directorul Dr. DAN
ARTHUR, Dr. LOHAN a spus c este un om de treab i c
e pcat c e paralizat, fiind un om foarte capabil i un
excepional psiholog.
Apoi a povestit c la el acas nu a fost dect de
dou ori i nici nu ndrznete s mearg, s nu se cread c
merge pentru soia acestuia cu care este foarte bine.
Apoi, Dr. LOHAN a nceput s povesteasc ce a
pit o bolnav internat n secia lui, n legtur cu
calitatea lui de psiholog a dr.[lui] DAN. Aceast bolnav,
dup internare, a fost la cabinetul directorului pentru
examen psihologic i pentru ncheierea17 tratamentului, dr.
DAN, dup ce a vzut biletul de trimitere, i-a spus
bolnavei c ea sufer din motive amoroase, iar bolnava,
fcnd o scen de histerie, a nceput s plng, s se revolte
i, n cele din urm, s cear s i se fac ieirea din
sanatoriu. Dar dr. DAN foarte calm a linitit-o pe bolnav
i a rugat-o s se aeze pe scaun i s renceap s-i
vorbeasc despre boal. Bolnava ntr-adevr s-a linitit,
pn la urm a recunoscut c dr. DAN i-a descoperit
tainele suferinei ei. Aceasta a povestit bolnava n salon
Dr.[lui] LOHAN i la celelalte bolnave i era ncntat de
calitile acestui doctor (dr. Arthur Dan n.n.).
ntrebat de surs dac soia dr.[lui] DAN se cam
plimb, cci a vzut-o de cteva ori prin gar, Dr. LOHAN
a spus rznd c probabil i caut i ea vreun amant.
ss.Munteanu Gheorghe18
Cu aceti pai terapeutici efectuai de un mare psihiatru,
marcat de neputina de a pi cu adevrat, ncheiem
incursiunea noastr prin arhivele Securitii. Dan Arthur,
intuit fiind ntr-un fotoliu, aflat ns n centrul ateniei
pacienilor si, al colegilor-discipoli i al informatorilor
Securitii, a jucat rolul unui psihiatru formator. Un
formator direct pentru cei care s-au dus s nvee de la el, i
indirect pentru cei care au construit n jurul lui o legend a
practicrii unei psihiatrii eliberate de stringena
politicului. Reasamblarea documentelor din dosarele
CNSAS seamn cu ncercarea de a reconstitui
evenimente ca ntr-o docu-dram, necesar pentru a
nelege limbaje i comportamente dintr-o epoc dificil de
neles. Mai cu seam, dac inem seama c, aidoma
teatrului clasic, unitatea de loc i de aciune a fost pstrat
n cazul dosarului lui Dan Arthur, drama psihiatrului
paraplegic derulndu-se pe scena singular a celei mai
inedite instituii psihiatrice, din Romnia comunist,
Sanatoriul Republican de Nevroze de la Svrin.

12

Ibidem, f. 5.
Ibidem, f. 10.
14
Ibidem, f. 11.
15
Ibidem.
16
Ibidem, f. 37.
17
La redactare, ofierul de Securitate, nefiindu-i familiar sintagma medical iniierea tratamentului, a consemnat ncheierea tratamentului.
13

63

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Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

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65

Instructions for authors

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66

Romanian Journal of Psychiatry, vol. XVIII, No.2, 2016

Address to send the manuscripts is:

REVISTA ROMN DE PSIHIATRIE
ASOCIAIA ROMN DE PSIHIATRIE I PSIHOTERAPIE
Prof. Dr. Dan PRELIPCEANU
Clinical Hospital of Psychiatry Prof. Dr. Alexandru Obregia
os. Berceni 10, sector 4, 041914 Bucureti
Tel./Fax: +40-21-334.84.06
E-mail: aliat@artelecom.net
Contact: Viorel Roman web editor
E-mail: aliat@artelecom.net
Tel. +40-21-334.84.06
www.e-psihiatrie.ro/revista - print edition
www.romjpsychiat.ro - online edition

67

ROMANIAN JOURNAL
OF PSYCHIATRY
CONTENTS
EDITOR-IN-CHIEF:
CO-EDITORS:

SPECIAL ARTICLES
& Depression and Suicide in Women Characters of The Early 20th
Century
Ionu I. Jeican, Doina C.M. Cozman

29

REVIEW ARTICLES
&

The Deluded Person as an Actor in an Aberrant Scenario

Mircea Lzrescu, Marinela Hurmuz

34

&

&

The Religious Delusion and the Multiple Realities Perspective

Mircea Lzrescu, Jenica Blajovan, Marinela Hurmuz

39

Antipsychotic Treatment and Psychosocial Functioning in

Schizophrenia Results From Romanian Cohort of Eufest Study
Valentin P. Matei, Alexandra Mihailescu, Traian Purnichi,
Ruxandra M. Al-Bataineh

45

Depression in Young Adults With Chronic Somatic Illness an

Analysis of 1970 British Cohort Study
Alexandra I. Mihailescu, Valentin P. Matei, Liliana V. Diaconescu,
Ruxandra Al-Bataineh, Traian Purnichi

51

CLINICAL CASE
&

Resistant Psychosis in a Patient With Coexisting Beta-thalassemia and

Latent Toxoplasmosis
Alexandra Barbilian, Dan Prelipceanu

55

THE HISTORY OF ROMANIAN PSYCHIATRY

&

The Security File of the Psychiatrist Dan Arthur, a Possible

Docu-Drama
Mihai Ardelean

INSTRUCTIONS FOR AUTHORS

59

64

Romanian Journal of Psychiatry and Psychotherapy is recognized in Romanian National Council

for Scientific Research in Higher Education, starting with January 2010, at B+ category

Romanian Journal of Psychiatry and Psychotherapy is indexed in the international data base Index
Copernicus Journal Master List, starting with 2009.

APR

ASSOCIATE EDITORS:
Doina COZMAN
Liana DEHELEAN
Marieta GABO GRECU
Maria LADEA
Cristinel TEFNESCU
Ctlina TUDOSE
Executive editors: Elena CLINESCU
Valentin MATEI

ORIGINAL ARTICLES
&

Dan PRELIPCEANU
Drago MARINESCU
Aurel NIRETEAN

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

Doctors subscribed to this journal receive 5 CME credits / year.

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

www.romjpsychiat.ro