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REVISTĂ DE EDUCAŢIE MEDICALĂ CONTINUĂ
Anul XV • Nr. 64 (1) 2021 • DOI: 10.26416/Psih.64.1.2021

RESEARCH
INPATIENT
PSYCHIATRIC
SERVICES USE
DURING THE
COVID-19 PANDEMIC
IN ROMANIA
ORIGINAL ARTICLE
Personological
vulnerability in the
artistic profession.
The assessment of
personality traits through
DECAS and PID-5 scales
page 6

CASE REPORT
Psychiatric
psychopathology in
the context of multiple
sclerosis – diagnostic and
therapeutic challenges
page 22

PSYCHOTHERAPY
General view regarding
the different types of
psychotherapy used for
the treatment of drug
addiction
page 46
PHOTO: SHUTTERSTOCK
 editorial
Alianţa Română de Psihiatrie
și Psihoterapie, între memorii,
propuneri, speranţe…
Acordarea de îngrijiri psihiatrice de
înaltă calitate pacienților, în special în
cadrul Uniunii Europene, este o obligație
a statului, o datorie a profesioniștilor din
domeniul sănătății mintale și un drept
fundamental al pacienților. Finanțarea
sistemelor de sănătate din statele mem-
bre ale UE este de aproximativ 10% din
PIB-ul fiecărei țări. În România, pe lângă
alocarea insuficientă de fonduri pentru
sănătate, serviciilor de sănătate mintală
le este atribuit un procentaj foarte mic
din această alocare.
Noul context al pandemiei de CO-
VID-19, precum și evenimentele tragi-
ce din ultimii ani legate de persoane cu
tulburări psihice (de exemplu, crimele de
la Săpoca, împușcarea recentă a unui pa-
cient cu tulburare bipolară în București,
incendiul de la Spitalul de Psihiatrie din
Craiova) impun abandonarea pasivității
autorităților și adoptarea de măsuri ur-
gente de reformă reală a sistemului de
asistență psihiatrică și dezvoltarea unui
pachet de reforme în domeniul sănătății
mintale. În acest sens, Asociația Română
de Psihiatrie şi Psihoterapie (ARPP), în
calitatea sa de for reprezentativ naţional
al specialiştilor psihiatri din România, a
înaintat în anul 2020 un memoriu către
Ministerul Sănătăţii, care s-a soldat cu
un răspuns irelevant față de cererile for-
mulate (a se vedea la: https://e-psihiatrie.
ro/raspunsul-ministerului-sanatatii-la-
memoriul-arpp-poate-fi-consultat-aici/).
Iată că în acestă primăvară avem
ocazia să solicităm ameliorarea situaţiei
sistemului de sănătate mintală, printr-
un nou contract-cadru încheiat cu Casa
Reclamă Psih 64(1)0101
Naţională de Asigurări de Sănătate
(CNAS). Consiliul director al ARPP, în
urma consultărilor cu membrii asoci-
aţiei, a înaintat o serie de propuneri
de îmbunătățire a proiectului propus
pentru contractul-cadru. Redăm mai
jos câteva din schimbările la proiectul
trimis de asociație.
Anul XVI • Nr. 64 (1/2021)
Acordarea la distanţă a consulta-
ţiei, a terapiilor psihiatrice și a ser-
viciilor conexe: „consiliere psihiatrică Prof. univ. dr.
Doina Cozman
nespecifică individuală şi familială,
Redactor-șef
psihoterapie de grup (psihoze, tulburări
obsesiv-compulsive, tulburări fobice,
tulburări de anxietate, distimii, adic-
ţii), psihoterapie individuală (psihoze, Servicii medicale în unităţi sanitare cu
tulburări obsesiv-compulsive, tulburări paturi. Secţiunea a 4-a. Obligaţiile şi
fobice, tulburări de anxietate, distimii, drepturile spitalelor)(2).
adicţii, tulburări din spectrul autist),
terapie cognitivă comportamentală” Implementarea reformării sistemului de
(conform Anexei 7)(1). asistenţă psihiatrică din România este o
Notă de fundamentare, Secţiunea a necesitate stringentă și obligă la acţiuni
2-a. Schimbări preconizate(2): medicii adecvate şi concrete ale autorităţilor, mai
de familie să prescrie pentru pacienţii ales în contextul pandemiei de COVID-19.
asiguraţi medicamente recomandate Să sperăm că cererile ARPP legate de
în scrisoarea medicală eliberată şi de noul contract-cadru vor fi auzite, de aceas-
medici care nu desfăşoară activitate tă dată, de către cei care decid sănătatea
în relaţie contractuală/convenţie cu României!
CNAS (a se vedea Capitolul I. Asistenţa
medicală primară. Secţiunea a 3-a.
Obligaţiile şi drepturile furnizorilor de
servicii medicale)(2).
1. https://www.formaremedicala.ro/au-aparut-normele-co-
Creşterea numărului de norme (ne- ca-2018/
cesar de medici) în contract cu CNAS 2. Proiect HG pentru aprobarea pachetelor de servicii şi a
Contractului-cadru care reglementează condiţiile acordării
în asistenţa medicală ambulatorie de asistenţei medicale, a medicamentelor şi a dispozitivelor
specialitate, cu prioritizare în funcţie de medicale, tehnologiilor şi dispozitivelor asistive în
cadrul sistemului de asigurări sociale de sănătate pentru
deficitul în anumite macroregiuni. anii 2021-2022. Publicat la: 02.03.2021, Transparenţă
Posibilitatea încheierii unui con- decizională. CNAS. http://www.cnas.ro/page/transparenta-
decizionala-2021.html
tract individual cu CNAS şi cu fracţi-
une de normă (jumătate de normă sau
¼ din normă) – a se vedea Capitolul II,
Secţiunea 1(2).
Centrele de sănătate mintală (CSM)
să aibă posibilitatea de a încheia con-
tracte cu CNAS pentru îngrijiri medi-
cale la domiciliu (Capitolul VIII. Îngrijiri
medicale la domiciliu)(2).
Pachetul minimal să cuprindă și
servicii psihiatrice pentru adicţii (a
se vedea Anexa 1, Capitolul I. Pachetul
minimal de servicii)(2).
Înfiinţarea şi bugetarea de depar-
tamente/compartimente de psihiatrie
de legătură, în toate spitalele judeţe-
ne/spitalele de urgenţă (Capitolul VI.
3
 Anul XV • Nr. 64 (1) aprilie 2021
summary

ORIGINAL ARTICLE REDACTOR-ȘEF

Prof. univ. dr. Doina COZMAN

6 Personological vulnerability in the artistic profession. The assessment REDACTOR-ȘEF ADJUNCT

Șef lucr. univ. dr. Bogdan NEMEȘ
of personality traits through DECAS and PID-5 scales COMITET EDITORIAL
Monica A. Coman, Istvan Z. Szasz, Aurel P. Nireștean Prof. univ. dr. Cătălina TUDOSE
Prof. univ. dr. Pompilia DEHELEAN
Prof. univ. dr. Roxana CHIRIŢĂ

14
Prof. univ. dr. Iuliana DOBRESCU
Psychosocial factors involved in preterm birth Prof. univ. dr. Dragoș MARINESCU
R. Stoenescu, M. Stancu, L.E. Andrei, I. Sandu, I. Jipescu, F. Rad, I. Dobrescu Prof. univ. dr. Aurel NIREȘTEAN
Conf. univ. dr. Horea George COMAN
Conf. univ. dr. Radu-Virgil ENĂTESCU
Conf. univ. dr. Maria LADEA
Conf. univ. dr. Ion UDRIȘTOIU
CASE REPORT Șef lucr. univ. dr. Ciprian BĂCILĂ
Șef lucr. univ. dr. Lavinia DUICA

22 Psychiatric psychopathology in the context of multiple sclerosis – Șef lucr. univ. dr. Ana GIURGIUCA
Șef lucr. univ. dr. Dana-Cristina HERŢA
diagnostic and therapeutic challenges Asist. univ. dr. Cătălina GIURGI-ONCU
Dr. Ovidiu ALEXINSCHI
Cristian Petrescu, Gabriela Marian, Cristian Traian Sima, Carmen Diana Dr. Roxana STOEAN
Dumitru, Brîndușa Ecaterina Focșeneanu Dr. Simona TĂMĂȘAN
COMITET INTERNAŢIONAL
Acad. prof. dr. Vasile CHIRIŢĂ (Iași, România)
Prof. dr. HC Șerban IONESCU (Paris, Franţa)

RESEARCH Prof. dr. Jean-Pierre Kahn (Nancy, Franţa)

Acad. Emeritus prof. dr. Mircea LĂZĂRESCU (Timișoara, România)
Assoc. prof. dr. Alina MARIN (Kingston, Canada)
26 Inpatient psychiatric services use during the COVID-19 pandemic in Prof. dr. HC Juan E. MEZZICH (New York, SUA)
Dr. Nick MIHĂILESCU (Montreux, Elveţia)
Romania Dr. Davor MUCIC (Copenhaga, Danemarca)
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Prof. univ. dr. Dan PRELIPCEANU (România)

32 Individual personological features in the professional choice of Acad. prof. dr. HC Sorin RIGA (București, România)
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 original article
The assessment of personality
Monica A. Coman1,2,3,
Istvan Z. Szasz1,2,3,
Aurel P. Nireștean1,2
1. Department of Psychiatry,
“George Emil Palade” University
of Medicine, Pharmacy, Sciences
and Technology of Târgu-Mureș,
România
2. Psychiatry Clinic II
Mureș County Clinical Hospital,
Târgu-Mureș, România
3. Psychobiomed Center SRL,
România
Corresponding author:
Aurel P. Nireștean
E-mail: aurelnirestean@yahoo.com
6 Anul XVI • Nr. 64 (1/2021)
Personological vulnerability
in the artistic profession
traits through DECAS
and PID-5 scales
Abstract
The connection between creativity and psychopathology is
belatedly highlighted in the specialized literature, but the
interest for this subject has increased over the last few years.
This study will analyze particularly artists from Romania,
who come from a different social, historical, cultural and
economic context. They are often marginalized, perceived
as “strange” or stigmatized. This is due to their way of being
more nonconformist, more relaxed or of their original outfit.
Objective. We wish to assess those facets of the personality
dimensions that motivate and maintain artistic talent,
which can influence the chances of success, highlighting
those dimensions that facilitate the professional options
developed, according to personal talent and skills.
Materials and method. We have included in our study a
batch of 24 artists from various fields of activity, who filled
out the Personality Inventory for Diagnostic and Statistical
Classification Manual of Mental Disorders 5th Edition (PID-5)
form, and the Openness, Extraversion, Conscientiousness,
Agreeableness, Emotional Stability (DECAS) form.
Results. The correlations between increased openness,
eccentricity and grandiosity can be advantageous
factors in the artist profession. The increased values
of conscientiousness can lead to the development of
certain obsessive-compulsive type personality traits that
can be beneficial under certain circumstances and can
lead to perfectionism and perseveration. The unusual
beliefs, suspiciousness and perceptual dysregulation
are disadvantageous traits that can be the starting
point for psychotic pathological manifestations.
Conclusions. There are dimensions that predispose to an
increased aesthetic sense, creativity and fantasy, which can
be important factors in choosing one’s profession, but can
also create a vulnerability to forays into psychopathology.
Keywords: profession, creativity, personality, art,
abnormality
Recieved:
15.03.2021 Vulnerabilitatea personologică la artiști. Evaluarea trăsăturilor de
Accepted:
29. 03.2021 personalitate prin scalele DECAS și PID-5
Suggested citation for this article: Coman MA, Szasz IZ, Nireștean AP. Personological vulnerability in the artistic profession. The assessment of personality traits
through DECAS and PID-5 scales. Psihiatru.ro. 2021;64(1):6-12
Rezumat
Legătura între creativitate și psihopatologie este pusă tardiv
în evidență în literatura de specialitate, însă interesul pentru
această temă a crescut în ultimii ani. Acest studiu analizează
în mod specific artiști din România, care provin dintr-un
context social, istoric, cultural și economic diferit. Adeseori ei
sunt marginalizați, priviți ca fiind „ciudați” sau stigmatizați,
din cauza felului lor de a fi mai nonconformiști, mai destinși
și a ținutei originale.
Obiectiv. Dorim să evaluăm acele fațete ale dimensiunilor
personalității care motivează și întrețin talentul artistic,
care pot influența șansele de succes, cu punerea în evidență
a acelor dimensiuni care facilitează opțiunile profesionale
elaborate, conform talentului și aptitudinilor personale.
Materiale și metodă. Am inclus în studiul nostru un lot de
24 de artiști din diverse arii de activitate, care au completat
Inventarul de personalitate pentru Manualul de diagnostic
și clasificare statistică a tulburărilor mintale ediţia a
5-a (PID-5) și Chestionarul Deschidere, Extroversiune,
Conștiinciozitate, Agreabilitate, Stabilitate emoțională
(DECAS).
Rezultate. Corelațiile între deschiderea crescută,
excentricitate și grandiozitate pot fi factori favorizanți în
profesia artistică. Valorile crescute ale conștiinciozității
pot duce la dezvoltarea unor trăsături de personalitate de
tip obsesiv-compulsiv care pot fi avantajoase în anumite
condiții și pot conduce la perfecționism și perseverenţă.
Credințele bizare, suspiciozitatea și dereglarea perceptuală
sunt trăsături defavorizante care pot fi punctul de plecare al
unor manifestări psihopatologice de tip psihotic.
Concluzii. Există dimensiuni care predispun spre un simț
crescut estetic, spre creativitate și fantezie, care pot fi factori
importanți în opțiunea profesională, dar care pot crea o
vulnerabilitate spre incursiuni în psihopatologie,
Cuvinte-cheie: profesie, creativitate, personalitate, artă,
anormalitate

Introduction
Art is a unique way of expressing the self, one’s own
thoughts, ideas, feelings, emotions, in close connec-
tion with certain social, economic, historical, political
and personal contexts.
Art may be defined and seen as a reflection of the
creative side of the individual that essentially renders
a personal, subjective affective experience. Art is one
of the dimensions that define the human, next to the
affective, cognitive and volitional component (1).
The preoccupation and interest for creativity, after
1950, is motivated by the importance that this dimension
has on the elements of social, economic and cultural
nature, an interest that is demonstrated by the large
number of publications on this subject, particularly in
the international literature, especially in recent years(2).
The interferences between mental disorders and
creativity were first described in literature in the
1970s by Nancy Andreasen, at the University of Iowa,
on a batch of 30 writers (3).
Figure 1. Correlations between the openness to experience dimension and the facets of PID-5 form
Anul XVI • Nr. 64 (1/2021)
psihiatru
The first researches indicated a connection between
creativity and psychopathology, creative functioning
and unusual thinking, affective symptoms, personality
traits and facets, and behavioural characteristics (4).
The studies performed and the publications on
this subject involve dimensions such as neuroticism,
openness, agreeableness and extraversion, which are
increased in the groups of artists. Substance use is
often encountered, to stimulate creativity (5).
Objective of the study
The main objective of the study: we set out to assess
those facets of the personality dimensions that mo-
tivate and maintain the artistic talent, and always
inf luence the chances of success, and the way it is
still used in the practice of the profession.
Expectations: highlighting the dimensions involved
in the various psychopathological decompensations
of the assessed personality, the way in which they
influence the dynamics of professional roles.
7
original article
Materials and method
We included in our study a batch (N=24) from dif-
ferent professional artistic fields: actors, dancers,
musicians, painters, writers, theatre critics, street
artists, with different age, gender and background,
and who filled out the PID-5 and DECAS forms, in the
period 2018-2019. The batch was divided into three
groups: actors, musicians and visual artists.
The collected data have been obtained prospectively.
The statistical program used was PSPP. The test
for determining the distribution of parameters was
conducted using the Kolmogorov-Smirnov formula.
The Personality Inventory for DSM-5 (PID 5)
The Personality Inventory for DSM-5 is a 220-item
self-rated personality traits assessment scale. PID-5 is
a dimensional questionnaire based on the alternative
model DSM‑5, a brief form of the Five-Factor Model
in which there are stressed the maladaptive traits. It
assesses 25 personality trait facets, including: anhe-
donia, anxiousness, attention seeking, callousness,
Figure 2. Correlations between the extraversion dimension and the facets of PID-5 form
8 Anul XVI • Nr. 64 (1/2021)
deceitfulness, depressivity, distractibility, eccentricity,
emotional lability, grandiosity, hostility, impulsivity,
intimacy avoidance, irresponsibility, manipulativeness,
perceptual dysregulation, perseveration, restricted af-
fectivity, rigid perfectionism, risk taking, separation
insecurity, submissiveness, suspiciousness, unusual
beliefs and experiences, and withdrawal. The 25 specific
facets (groups of 3-9) can be combined to yield indices
of the five broader trait domains: negative affectivity
(emotional lability, anxiousness, separation insecurity),
detachment (withdrawal, anhedonia, intimacy avoid-
ance), antagonism (manipulativeness, deceitfulness,
grandiosity), disinhibition (irresponsibility, impulsiv-
ity, distractibility), psychoticism (unusual beliefs and
experiences, eccentricity, perceptual dysregulation)(7).
DECAS – Openness, Extraversion, Conscientiousness,
Agreeableness, Emotional Stability
This is a personality trait assessment instrument
based on the Big Five Factor Model, created by Pro-
fessor Florin Alin Sava (MD, PhD), comprising 97

­ uestions, with “true/false” type answers. It is based on
q Results
a dimensional model with five dimensions: openness,
extraversion, conscientiousness, agreeableness and
emotional stability, each domain having six facets,
described by Costa and McCrae in 1985.
It is a questionnaire based on a dimensional model
with five dimensions: openness, extraversion, consci-
entiousness, agreeableness, and emotional stability,
each domain having five facets:
1. E xtraversion: warmth, gregariousness, asser-
tiveness, activity, excitement-seeking, positive
emotions.
2. A greeableness: trust, straightforwardness, altru-
ism, compliance, modesty, tender-mindedness.
3. Neuroticism (as opposite to emotional stabil-
ity): anxiety, anger-hostility, depression, self-
consciousness, impulsiveness, vulnerability.
4. Conscientiousness: competence, order, dutifulness,
achievement striving, self-discipline, deliberation.
5. O penness: fantasy, aesthetics, feelings, actions,
ideas, values (8).
Figure 3. Correlations between the conscientiousness dimension and the facets of PID-5 form
Anul XVI • Nr. 64 (1/2021)
psihiatru
The 24 persons who filled out the questionnaire
had ages between 20 and 88 years old (18 males and 6
females). They all came from urban areas (Timișoara
and Sibiu).
Figures 1, 2, 3, 4 and 5 show the correlation coef-
ficient between the dimensions of the DECAS form
and the facets of the PID-5 form.
Discussion
We wish to highlight the advantageous and disad-
vantageous traits in the artist profession.
The correlations between increased openness, ec-
centricity and grandiosity can be advantageous factors
in the artistic profession, but manipulativeness and
risk taking, depending on certain circumstances, can
be both advantageous and disadvantageous.
Unusual beliefs and suspiciousness as traits present
in individuals with increased openness can lead to
psychopathological decompensations.
9
original article
Increased extraversion, together with low values
of withdrawal and trauma avoidance, as well as high
values of attention seeking, can be advantageous fac-
tors in an artist’s destiny, but impulsivity does not
favour the artistic career.
High values of conscientiousness may lead to the
development of certain obsessive-compulsive type
personality traits that can be advantageous under
certain circumstances as support for perfectionism,
perseveration, openness to details and nuances. Unu-
sual beliefs, suspiciousness and perceptual dysregu-
lations can be disadvantageous traits and a starting
point for psychotic pathological manifestations.
Agreeableness and emotional stability described
in the Big Five theory are domains related to nor-
mality, therefore any negative correlation between
these domains and the pathological facets of PID-5
become protective and advantageous factors in the
professional growth.
Figure 4. Correlations between agreeableness dimension and the facets of PID-5 form
10
Openness, extraversion and conscientiousness are
defining domains which, even though they have a
great inf luence on the evolution and growth of the
artists professions, they may lead to psychopatho-
logical decompensations: an exaggerated openness
leads to antagonism, disinhibition and psychoticism,
extraversion to disinhibition, and conscientiousness
leads to negative affectivity and psychoticism.
Conclusions
High values of openness predispose to an aesthetic
sense, creativity and fantasy, that can be important
factors in choosing one’s profession.
The correlations between extraversion and atten-
tion seeking represents an advantageous trait in the
artist profession.
A moderate conscientiousness is a key factor in reach-
ing the success, but very high values are associated with
a vulnerability for psychopathological decompensations.
Anul XVI • Nr. 64 (1/2021)
 psihiatru

Figure 5. Correlations between the emotional stability dimension and the facets of PID-5 form

Figure 6. Correlations between DECAS and the PID-5 domains

Anul XVI • Nr. 64 (1/2021)

11
original article
Agreeableness and emotional stability that include
a mature defence mechanism lead to a durable profes-
sional stability.
The dimensional assessment of the personality
traits attests to being a particular endeavour in ac-
knowledging the personal abilities assigned to the
professional role.
The interdimensional correlations developed
by this study may also be used in shaping the
professional abilities, as well as in the therapeutic
exchange of personality disorders psychopathological
decompensation n
12
References
1. Rusu M. Art and Conscious – philosophical and psychological dimensions of the
artistic creation, Iași, Ars Longa Publishing. 2014, 5-6.
2. Popescu G. The Psychology of Creativity – 3rd Edition, Bucharest, Fundația
România de Mâine Publishing. 2007, 5.
3. Andreasen NC. Creativity and Mental Illness: Prevalence Rates in Writers and
their First Degree Relatives. American Journal of Psychiatry. 1987;144:1288–1292.
4. Martindale C, Glover JA, Ronning RR, Reynolds CR. Personality, situation and
creativity. Handbook of creativity. New York: Plenum; 1989, 211–321.
5. Pavitra KS, Chandrasekar CR, Choudhury P Creativity and mental health: A
profile of writers and musicians. Indian J Psychiatry. 2007 Jan-Mar;49(1):34–43.
6. APA. DSM – Diagnostic and statistical manual of mental disorders – fifth edition.
Washington DC: American Psychiatric Publishing, 2013.
7. Sava F. DECAS Personality Inventory. User’s Manual, Timișoara. ArtPress, 2008.
Reclamă Psih 64(1)0103
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Psychosocial factors involved

R. Stoenescu1,
M. Stancu1,3,
L.E. Andrei1,2,
I. Sandu2,
I. Jipescu , F. Rad1,2,
4
I. Dobrescu1,2
1. “Carol Davila” University
of Medicine and Pharmacy,
Bucharest, Romania
2. “Prof. Dr. Alexandru Obregia”
Psychiatry Hospital, Bucharest,
Romania
3. “Mina Minovici” National
Institute of Legal Medicine,
Bucharest, Romania
4. Institute of Neurology and
Psychiatry, Bucharest
Corresponding author:
Mihaela Stancu
E-mail: mihaela.stancu@drd.umfcd.ro
in preterm birth
Abstract
Introduction. Preterm birth is a significant problem in
maternal and fetal health worldwide, being one of the
most common causes of infant mortality and morbidity. Its
prevalence is alarmingly high, the causes being unknown
in a substantial proportion of cases. However, there
are a considerable number of biological, psychological
and social factors that have been studied over the years
to identify an etiological pattern of prematurity.
Purpose. The present research aimed to identify
factors related to living and environmental conditions
that may contribute to the development of pregnancy
and that may lead to a premature birth.
Materials and method. To collect the data, an online
questionnaire was used for mothers who had given
birth no more than 24 months before completing
the questionnaire, distributed through social media
platforms on specific groups. The resulting information
was collected in a database, using Microsoft Office Excel
2019, the data being subsequently statistically processed
using Microsoft Office Excel 2019 and SPSS 20.
Results. The high level of education was identified as a
protective factor against a premature birth. Also, among
mothers employed during pregnancy, the percentage
of premature births was much lower than among those
without a job. Regarding marital status, no statistically
significant correlation was identified between the
mother’s marital status and the degree of prematurity.
Conclusions. The results of this research suggest that
certain factors related to living and environmental
conditions may contribute to the development of the
pregnancy and lead to a premature birth. These results
could be a starting point for further research to analyze
the psychosocial factors that influence pregnancy.
Keywords: preterm birth, psychosocial factors, online
questionnaire, protective factors
Rezumat
Introducere. Nașterea prematură reprezintă o problemă
semnificativă în domeniul sănătății materno-fetale din întreaga
lume, fiind una dintre cele mai frecvente cauze de mortalitate și
morbiditate infantilă. Prevalența sa este inacceptabil de mare,
iar cauzele sunt necunoscute într-o proporție substanțială de
cazuri, însă există un număr considerabil de factori biologici,
psihologici și sociali care au fost studiați de-a lungul anilor în
vederea identificării unui model etiologic al prematurității.
Scop. Cercetarea de față și-a propus să identifice factorii legați
de condițiile de viață și mediu care pot contribui la desfășurarea
sarcinii și care pot conduce la o naștere prematură.
Materiale și metodă. Pentru colectarea datelor s-a folosit un
chestionar online adresat mamelor care au avut o naștere în
urmă cu cel mult 24 de luni anterior completării chestionarului,
distribuit prin intermediul platformelor de socializare, pe
grupurile de profil. Informațiile rezultate au fost cuprinse într-o
bază de date, folosind Microsoft Office Excel 2019, datele fiind
ulterior prelucrate statistic cu ajutorul programelor Microsoft
Office Excel 2019 și SPSS 20.
Rezultate. S-a identificat nivelul educațional ridicat ca factor
protector față de o naștere prematură. De asemenea, în rândul
mamelor angajate pe parcursul sarcinii, procentajul nașterilor
premature a fost mult mai mic decât în rândul celor fără loc de
muncă. În ceea ce privește starea civilă, nu a fost identificată o
corelație semnificativă statistic între statusul marital al mamei
și gradul de prematuritate.
Concluzii. Rezultatele cercetării de față sugrează că anumiți
factori legați de condițiile de viață și mediu pot contribui la
desfășurarea sarcinii și pot conduce la o naștere prematură.
Aceste rezultate ar putea fi un punct de plecare pentru
cercetări ulterioare care să analizele factorii psihosociali care
influențează sarcina.
Cuvinte-cheie: naștere prematură, factori psihosociali,
chestionar online, factori protectori

Recieved:
22.03.2021 Factori psihosociali implicați în nașterea prematură
Accepted: Suggested citation for this article: Stoenescu R, Stancu M, Andrei LE, Sandu I, Jipescu I, Rad F, Dobrescu I. Psychosocial factors involved in preterm birth.
02.04.2021 Psihiatru.ro. 2021;64(1):14-20

Introduction identified that span all subtypes and populations. Also, a

Preterm birth (PTB; less than 37 weeks of gestation)
remains a significant burden both individually and in our
society. The World Health Organization (WHO) estimated
in 2016 that the proportion of premature births varied
between 5% and 18% globally, with the rate increasing in
some countries(3). While many sociodemographic, nutri-
tional, medical, obstetrical and environmental factors have
been shown to increase the risk of spontaneous preterm
birth, its etiology remains imperfectly understood(4,5). De-
spite decades of study, few risk factors for PTB have been
significant number of PTBs do not have a clearly reported
risk factor. Although a number of maternal characteristics
have been shown to be associated with specific subtypes
of PTB in one or more populations, differences between
definitions of PTB in several studies and consideration
of subtypes led to variable conclusions. Elucidating the
commonalities between the determinant factors studied
in this research can help us better understand the etiology
of PTB and can lead to strategies to reduce the cumulative
burden of PTB(6,7).

14 Anul XVI • Nr. 64 (1/2021)


Of all the known risk factors of premature birth,
psychosocial factors form a complicated collection,
which includes a multidimensional spectrum of in-
terdependent mediation mechanism. Understanding
these interconnected mechanisms is vital for design-
ing targeted interventions to reduce preterm births(8).
There are studies that describe a socio-medical model
to explain the interaction of psychosocial factors
with certain biomedical fields, such as preexisting
conditions, pregnancy complications and maternal
behaviors (9).
Regarding the age of the mother, the risk of pre-
mature birth is high in both adolescent pregnancies
and in elderly mothers (10-12). A meta-analysis of cohort
studies found that nulliparous women under the age
of 18 years old have the highest risk of premature birth
in all age/parity categories (13). Premature birth in a
previous pregnancy remains a strong risk factor for
premature birth in a later pregnancy, as does maternal
nulliparity, as demonstrated in various researches,
such as those conducted by Kazemier or Ferrero (14,15).
The educational level of mothers is another factor
considered in the etiological model of PTB. According
to data published by Ruiz et al., low maternal educa-
tion was associated with premature birth, although
this aspect could not be separated from the link with
maternal age in the study (16). A study conducted in the
USA that considered maternal and paternal education,
maternal and paternal occupation, as well as family
income, found that levels of maternal and paternal
education were the best global predictors of preterm
birth. Mothers with a medium or low level of education
(less than 12 years) were identified as having a higher
chance of having a premature birth than mothers
with more education(17). In contrast, according to the
results published by Thompson et al., a relatively equal
increase in premature births was observed among
groups divided by the mother’s educational levels (18).
Also, the results of a study conducted in four European
countries (Denmark, Finland, Norway and Sweden)
showed that, compared to mothers with less than 12
years of education, mothers with more than 10 years
of education had similar high risks of preterm birth(19).
The marital status of the mother has been identified
in a large number of populations as a risk factor for pre-
mature birth, single mothers (defined as unmarried or
living without a partner) being the category subjected to a
higher degree of risk(20-26). There are several interdependent
reasons why being unmarried could increase the risk of
having a premature birth, some of which may be: greater
economic insecurity faced by single mothers(20,27-29), lack
of social or emotional support offered by a partner, or the
acute stress generated by the separation of the partner
during pregnancy(30-33).
The mothers’ job situation and the level of stress as-
sociated with the workplace have also been reported
to associate with preterm birth by some studies (17).
This can be explained by the fact that demanding
work schedules can alter sleep patterns and the neu-
Anul XVI • Nr. 64 (1/2021)
psihiatru
roendocrine balance of pregnancy, further generat-
ing stress (34,35). According to a study conducted in 16
European countries, mothers who had an extended
work schedule (more than 42 hours/week), a pro-
longed standing time (more 6 hours/day) and those
with lower job satisfaction were more likely to have
premature births (36).
It is well known that all these factors increase
the likelihood of adverse health outcomes; however,
their possible mechanisms of interaction, resulting
in preterm birth, have yet to be explored. The aim of
this paper was to examine the relationships between
identified maternal psychosocial risk factors, which
can act in a complex way to cause premature birth.
Methodology
The research presented in this paper was based on
an observational, retrospective, descriptive analysis
study. The information used in this research was
collected between April and August 2020. Given the
epidemiological context and the restrictions imposed,
data collection could not be done in a physical format
in hospital wards, which is why an online question-
naire was used, distributed through social platforms
on profile groups. In order to validate and confirm
the data, the respondents were asked to agree to be
contacted by phone.
The questionnaire was addressed to mothers who
had given birth no more than 24 months before com-
pleting the questionnaire. The purpose of the question-
naire was to obtain information on the progress of
pregnancy and premature births. The questionnaire
also included information on sociodemographic data
related to the mother (age, educational level, informa-
tion about the family situation, about the job etc.) and
the father. Also, data were collected on the mother’s
medical situation (chronic diseases, personal patho-
logical history, hereditary history) and on pregnancy
and birth (getting pregnant, number of pregnancies
stopped developing, complications, treatments etc.).
The data obtained by completing the online ques-
tionnaire were entered into a database using Microsoft
Office Excel 2019. Subsequently, the data were statisti-
cally processed using the Microsoft Office Excel 2019
and SPSS 20 programs.
Results
Of the 331 responses received to the online ques-
tionnaire, those that were incomplete and those in
which the birth occurred more than 24 months before
completion were excluded. Thus, 292 women were in-
cluded in the database, who gave birth at least once in
the last two years. The age of the mothers at the time
of completing the questionnaire was between 18 and
50 years old. The minimum age at birth was 18 years
old, and the maximum age was 48 years old, with an
average birth age of 30.11±4.76. The age of fathers at
birth ranged from 21 to 47 years old, with an average
of 33.08±4.76 years old.
15
original article

161
Figure 1. Number of
55.13% previous births

92
31.51%

39
13.36%

1st birth 2nd birth >2 births

160 138 Figure 2. Level of

47.26% education for mothers
140
120 91
100 31.16%
63
80 21.58%
60
40
20
0
Middle/Highschool University Postuniversity

Figure 1 shows the number of previous births. Thus,
55.15% (n=161) of the respondents were at the first birth,
31.51% (n=92) at the second birth, and 13.36% (n=39)
had more than two previous births.
More than half of the respondents were at their first
birth, at an average age of 30.11 years old. These figures
are in line with the global trend of increased average
age at which women have their first child. According to
the EUROSTAT report, the average age at which women
have their first child in the European Union was 29.9
years old for 2019, the average ages by country varying
between 26.4 and 31.3 years old(1).
Analyzing of the gestational age at which the birth
took place, it was found that 37.3% of women gave birth
starting with the gestational age of 37 weeks, in the
rest of the cases the birth occurred prematurely. Table
1 illustrates the distribution of degrees of prematurity,
as follows: grade 0 (birth is not considered premature
starting with week 37 of pregnancy), grade I (birth at
gestational age of 32-36 weeks), grade II (28-32 weeks),
grade III (<28 weeks).
The present research aimed to analyze the statistical
correlations between the mother’s living and environ-
mental conditions and prematurity, as well as between
the mother’s preexisting medical conditions and the
level of prematurity.
The applied questionnaire included data related to the
mother’s educational level. We mention that all 292 respond-
ents reported at least secondary education, completing
at least 10 grades or a vocational school, so mothers with
low or no education were not included in this study. This
distribution is among the limitations of the research, and
one possible explanation may be that most people who
use the virtual environment and online social groups to
obtain information and complete such questionnaires are
those with at least an average level of education. Figure 2

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Table 1 Distribution of degrees of prematurity

Frequency Percentage Valid percentage Cumulative percentage
0 109 37.3 37.3 37.3
Prematurity grade I 84 28.8 28.8 66.1
Valid II 56 19.2 19.2 85.3
III 43 14.7 14.7 100
Total 292 100 100

Table 2 Contingency table for studies and prematurity

Prematurity grade
Total
0 1 2 3
Count 5 26 19 13 63
Secondary education
% within Studies 7.9% 41.3% 30.2% 20.6% 100%
Count 58 16 11 6 91
Studies Postgraduate studies
% within Studies 63.7% 17.6% 12.1% 6.6% 100%
Count 46 42 26 24 138
University studies
% within Studies 33.3% 30.4% 18.8% 17.4% 100%
Count 109 84 56 43 292
Total
% within Studies 37.3% 28.8% 19.2% 14.7% 100%

illustrates the distribution of the educational level in the
studied sample. Most of the respondent mothers (138,
representing 47.26%) have a university degree. Ninety-one
respondents (representing 31.16%) have postgraduate stud-
ies, and 63 (representing 21.58%) have secondary education.
Table 2 illustrates the frequencies of degrees of prema-
turity according to the level of education of mothers. Thus,
significant differences are observed between the formed
groups. Of the 63 respondents with secondary education,
92.1% (58 subjects) gave birth before the gestational age
of 37 weeks, presenting a degree of prematurity (26/41.3%
grade 1; 19/30.2% grade 2; and 13/20.6% grade 3 prema-
turity). Of the group of mothers with university degrees,
66.7% had a degree of prematurity, only 46 (33.3%) giving
birth at term. The degrees of prematurity in the group
of mothers with university studies were distributed as
follows: 42 mothers gave birth between 32 and 36 weeks
(30.4%), 26 mothers between 28 and 32 weeks (18.8%),
and 24 mothers gave birth before the gestational age of
28 weeks (17.4%). Regarding mothers with postgraduate
studies, most gave birth at term – 58 mothers, represent-
ing 63.7% of this group. A rate of 33.3% of mothers with
postgraduate studies gave birth before the gestational
age of 37 weeks, as follows: 16 (17.6%) with grade I prema-
turity, 11 (12.1%) with grade II prematurity, and 6 (6.6%)
grade III prematurity.
The Chi-Square test revealed a statistically significant
correlation between the level of education of mothers
and the degree of prematurity (p=0.000).
Table 3 shows the frequencies of degrees of prematurity
according to the marital status of mothers: married;
divorced; unmarried, but with a partner; unmarried,
without a partner. In the chosen sample, 257 of the
respondents (representing 88%) were married, and 28
(representing 9.6%) were unmarried, but with a stable
partner. Only three respondents stated that they were
divorced, and only four that they were unmarried and
without a partner. Thus, in the sample formed, there
was a very small number of single mothers. Out of
married mothers, 101 (representing 39.3%) gave birth
at term, while 60.7% gave birth before the gestational
age of 37 weeks. From the group of unmarried mothers
but with a partner, 7 (representing 25%) gave birth at
term, and in the case of 21 of them there was a degree
of prematurity. The Chi-Square test did not identify a
statistically significant correlation between the mother’s
marital status and the degree of prematurity (p=0.115).
The distribution of marital status in the formed group
is one of the limitations of the study, as there was a very
small number of divorced mothers or partners.
Of the group formed, 80 respondents (representing
27.4%) were unemployed during pregnancy, while 212
(representing 72.6%) had a job during the period in which
they were pregnant. Next, the stress level of mothers at
the workplace during pregnancy and the correlations
between the stress level and the child’s prematurity level
were analyzed. Table 4 shows the frequencies of degrees
of prematurity according to the level of stress of mothers

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original article

Table 3 Contingency table for marital status and level of prematurity

Prematurity grade
Total
0 1 2 3
Count 101 72 52 32 257
Married
% within Marital status of the mother 39.3% 28% 20.2% 12.5% 100%
Count 1 1 0 1 3
Divorced
Marital % within Marital status of the mother 33.3% 33.3% 0% 33.3% 100%
status of
the mother Count 7 9 4 8 28
Unmarried, but with a partner
% within Marital status of the mother 25% 32.1% 14.3% 28.6% 100%
Count 0 2 0 2 4
Unmarried, without partner
% within Marital status of the mother 0% 50% 0% 50% 100.0%
Count 109 84 56 43 292
Total
% within Marital status of the mother 37.3% 28.8% 19.2% 14.7% 100%

Figure 3. Distribution
of prematurity levels for
11.80% mothers with and without
25% a job during pregnancy
20.30%

22.50%
26.90%

32.50%

41%
20%

Working Non-working

0 1 2 3

at work during pregnancy. Workplace stress was graded
into four levels: 0 (no workplace stress), 1 (minimum
workplace stress level), 2 (moderate workplace stress
level), and 3 (high stress at work). The assessment of
the stress level was a subjective one of the respondents.
Thus, reporting the level of stress at work is not done
according to an objective scale, but reflects the percep-
tion of each of the mothers on the discomfort felt at
work. Twenty-four of the respondents employed during
pregnancy (representing 11.3%) reported a job in which
they did not feel stress, 67 (representing 31.6%) reported
a minimum level of stress, 77 (representing 36.3%)
reported a moderate level of stress, and 44 (represent-
ing 20.8%) felt a high level of stress at work during the
period they were pregnant. Of the mothers who reported
a job without stress levels, half gave birth on term. Of
the total mothers who worked during pregnancy, 41%
gave birth at term, 26.9% gave birth between weeks
32 and 36, 20.3% gave birth between weeks 28 and 32,
and 11.8% before 28 weeks. Of the mothers without a
job during pregnancy, 80% gave birth before 37 weeks
of pregnancy (Figure 3). The Chi-Square test did not
identify a statistically significant correlation between
the mother’s stress level at work during pregnancy and
the degree of prematurity (p=0.644).
Discussion and conclusions
This paper aims to investigate whether, in addition to
medical factors related to parental health and hereditary
history, other factors can be identified as being involved
in pregnancy and childbirth. We started from the prem-
ise that the mother’s level of information, a stable living
environment and a good level of mental comfort during
pregnancy can positively influence the development of
pregnancy, can contribute in taking it to its term and to
a birth without complications.

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Table 4 Contingency table for the level of stress at work and the level of prematurity
Prematurity grade
Total
0 1 2 3
Count 12 6 3 3 24
0
% within Stress_munca 50% 25% 12.5% 12.5% 100%
Count 27 20 10 10 67
1
Workplace % within Stress_munca 40.3% 29.9% 14.9% 14.9% 100%
stress Count 28 20 19 10 77
2
% within Stress_munca 36.4% 26% 24.7% 13% 100%
Count 20 11 11 2 44
3
% within Stress_munca 45.5% 25% 25% 4.5% 100%
Count 87 57 43 25 212
Total
% within Stress_munca 41% 26.9% 20.3% 11.8% 100%

In the chosen sample, most women were giving birth
for the first time. The average age of mothers at birth
was 30.11 years old, in line with the growing average
European age at which mothers have their first child.
Eurostat reports the average age at first birth at 29.9
years old in the European Union for 2019, compared to
the average age at first birth of 28.7 years old in 2013.
Out of the group of 292 subjects, 109 mothers (repre-
senting 37.32%) gave birth at term, while in 183 moth-
ers (representing 62.68%), the birth occurred before 37
weeks. In 84 of the total subjects, there was a grade I
prematurity (representing 28.8% of the total subjects
and 45.9% of the prematurity cases), in 56 a grade II
prematurity (representing 19.2% of the total subjects
and 30.6% of the prematurity cases), and in 43, a grade
III prematurity (representing 14.7% of all subjects and
23.5% of cases of prematurity). The high percentage of
cases of prematurity in the chosen group is well above
the average reported by the European Union (for Ro-
mania, in 2015, 8.4% of births were premature)(2). This
very high percentage of premature births in the chosen
sample can be explained by the method of data collec-
tion, online, using groups dedicated to mothers. Thus,
it is possible that those mothers who have concerns
about pregnancy and prematurity are those who turn
to profile groups and are more willing and interested
in completing a questionnaire on research related to
prematurity.
Analyzing the educational level of mothers, it was found
that 21.58% of respondents had a secondary education,
47.26% had a university education and 31.16% had a
postgraduate education. Most subjects had higher edu-
cation (78.42%) and there were no subjects who reported
low-level education or no education. Analyzing the link
between the level of education and prematurity, a statisti-
cally significant correlation was found. In the group of
mothers with secondary education, only 7.9% gave birth
at term, compared to 33.3% in the group of mothers with
university education, and 63.7% in the group of mothers
with postgraduate education. Thus, it was found that an
increased level of education was correlated with taking
the pregnancy to term. This correlation can be explained
by the fact that a high educational level translates into a
correct and complete information of the mother about
the pregnancy and the measures she can take for a
normal development of the fetus. Also, the high level
of information can be associated with more frequent
medical examinations and more rigorous monitoring,
thus reducing the risk of a premature birth.
Next, the marital status of the mother was analyzed.
In the chosen sample, only seven of the respondents were
single mothers, unmarried and without a partner. A total
of 257 of the respondents (representing 88%) were mar-
ried, and 28 (representing 9.6%) were unmarried, but with
a stable partner. No statistically significant correlation
was identified between marital status and prematurity.
The analysis of the mother’s occupation revealed that
most of the respondents had a job during the pregnancy
– 212 of the subjects, representing 72.6%. Of these, 24
(representing 11.3%) reported a stress-free job, 67 (rep-
resenting 31.6%) reported a minimum level of stress, 77
(representing 36.3%) reported a moderate level of stress,
and 44 (representing 20.8%) felt a high level of stress at
work during the period when they were pregnant. Of
the mothers who reported a stress-free job, 50% gave
birth on term. Also, 40.3% of those who reported a low
level of stress, 36.4% of those who reported a moderate
level of stress, and 35.5% of those who reported a high
level of stress at work gave birth at term. No statistically
significant correlation was identified between stress at
the workplace and prematurity, but the percentage of
mothers who gave birth prematurely was much higher
among the women unemployed during pregnancy (80% of
unemployed mothers gave birth prematurely, compared
to 59% of those with a job during pregnancy, regardless
of the reported stress level).

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19
original article
The present research aimed to identify factors
related to living and environmental conditions that
may contribute to the development of pregnancy and
which may lead to a premature birth. The high level of
education was identified as a protective factor against
a premature birth. Also, among mothers employed
during pregnancy, the percentage of premature births
was much lower than among those without a job.
These results could be a starting point for further
research to analyze the psychosocial factors that
inf luence pregnancy, with premature birth remain-
ing a global public health priority. The development
of evidence-based strategies to prevent the onset of
prematurity, as well as to mitigate its effects on new-
borns, is needed, especially in low-resource settings.
The volume and quality of data on PTB risk factors
vary between states, preventing accurate conclusions
globally. Thus, further research is needed on the dis-
covery of spontaneous mechanisms of PTB, in order
to be better predicted, prevented and controlled by
improving information in the population, prenatal
care and establishing favorable social environments
for pregnant women.
1. Eurostat, Data explorer, Fertility indicators.
References
2. European Perinatal Health Report, 2015, Europeristat.
3. World Health Organization, 2016. Preterm Birth. Available online at World
Health Organization. http://www.who.int/mediacentre/factsheets/fs363/en/.
4. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of
preterm birth. Lancet. 2008;371(9606):75-84.
5. Muglia LJ, Katz M. The enigma of spontaneous preterm birth. N Engl J Med.
2010;362(6):529-35.
6. Jelliffe-Pawlowski LL, Baer RJ, Blumenfeld YJ, Ryckman KK, O’Brodovich HM,
Gould JB, Druzin ML, El-Sayed YY, Lyell DJ, Stevenson DK, Shaw GM, Currier RJ.
Maternal characteristics and mid-pregnancy serum biomarkers as risk factors
for subtypes of preterm birth. BJOG. 2015;122:1484–1493.
7. Vogel JP, Chawanpaiboon S, Moller AB, Watananirun K, Bonet M, Lumbiganon
P. The global epidemiology of preterm birth. Best Practice & Research
Clinical Obstetrics & Gynaecology. 2018; S152169341830079. doi:10.1016/j.
bpobgyn.2018.04.003  Epidemiology of preterm delivery in two birth cohorts with an interval of 20
8. Batra K, Pharr J, Olawepo JO, Cruz P. Understanding the Multidimensional
Trajectory of Psychosocial Maternal Risk Factors Causing Preterm Birth: A
Systematic Review. Asian Journal of Psychiatry. 2020;102436. doi:10.1016/j.
ajp.2020.102436  25. Vagero D, Koupilova I, Leon DA, Lithell UB. Social determinants of birthweight,
9. Misra D, Strobino D, Trabert B. Effects of social and psychosocial factors on risk of
preterm birth in black women. Paediatr Perinat Epidemiol. 2010;24(6):546–554.
10. Smith GC, Pell JP. Teenage pregnancy and risk of adverse perinatal outcomes
associated with first and second births: population based retrospective cohort
study. BMJ. 2001;323(7311):476.
11. Waldenström U, Aasheim V, Nilsen AB, Rasmussen S, Pettersson HJ, Schytt E, et
al. Adverse pregnancy outcomes related to advanced maternal age compared
with smoking and being overweight. Obstet Gynecol. 2014;123(1):104-12.
12. Carolan M. Maternal age ≥45 years and maternal and perinatal outcomes: a
review of the evidence. Midwifery. 2013;29(5):479-89.
13. Kozuki N, Lee AC, Silveira MF, Sania A, Vogel JP, Adair L, et al. The associations of
parity and maternal age with small-for-gestational-age, preterm, and neonatal
and infant mortality: a meta-analysis. BMC Public Health. 2013;13 Suppl 3:S2.
14. Kazemier BM, Buijs PE, Mignini L, Limpens J, de Groot CJ, Mol BW, et al. Impact
of obstetric history on the risk of spontaneous preterm birth in singleton
and multiple pregnancies: a systematic review. BJOG. 2014;121(10):1197-208;
discussion 209.
15. Ferrero DM, Larson J, Jacobsson B, Di Renzo GC, Norman JE, Martin JN, et al.
Cross-Country Individual Participant Analysis of 4.1 Million Singleton Births
in 5 Countries with Very High Human Development Index Confirms Known
Associations but Provides No Biologic Explanation for 2/3 of All Preterm Births.
PLoS One. 2016;11(9):e0162506.
16. Ruiz M, Goldblatt P, Morrison J, Kukla L, Švancara J, Riitta-Järvelin M, et al.
Mother’s education and the risk of preterm and small for gestational age birth:
a DRIVERS meta-analysis of 12 European cohorts. J Epidemiol Community Health.
2015;69(9):826-33.
17. Parker JD, Schoendorf KC, Kiely JL. Associations between measures of
socioeconomic status and low birth weight, small for gestational age, and
premature delivery in the United States. Ann Epidemiol. 1994;4(4):271–278.
18. Thompson JMD, Irgens LM, Rasmussen S, Daltveit AK. Secular trends in socio-
economic status and the implications for preterm birth. Paediatric and Perinatal
20
Research limitations
The method of obtaining the data can be considered
one of the limitations of this research. Taking into ac-
count the epidemiological context, it was decided to
collect the data through an online questionnaire. Online
application of questionnaires and scales can decrease
the veracity and accuracy of the data. In order to limit
the effects of this disadvantage, the selective contacting
of the subjects was chosen to confirm the completed
data. Obtaining data by using the profile groups on
social networks may have influenced the composition of
the study group, in which the percentage of premature
births was very high. This distribution can be explained
by the profile of mothers who turn to these groups, as
they are the ones who have encountered difficulties
during pregnancy or childbirth and seek opinions or
advice from people with the same type of problems. In
the future, depending on the epidemiological context,
the research can be extended and completed by apply-
ing questionnaires in the neonatology departments. n
Conflicts of interest
The authors declare that they have no conflict of interest.
Epidemiology. 2006;20:182–187.
19. Petersen CB, Mortensen LH, Morgen CS, Madsen M, Schnor O, Arntzen A, Gissler
M, Cnattingius S, Nybo Andersen A-M. Socio-economic inequality in preterm
birth: a comparative study of the Nordic countries from 1981 to 2000. Paediatric
and Perinatal Epidemiology. 2009;23:66–75.
20. Zeitlin JA, Saurel-Cubizolles MC, Ancel PY. The EUROPOP Group. Marital
status, cohabitation, and the risk of preterm birth in Europe: where births
outside marriage are common and uncommon. Pediatr Perinat Epidemiol.
2002;16(2):124–130. 
21. Berkowitz GS, Papiernik E. Epidemiology of preterm birth. Epidemiologic
Reviews. 1993;15:414–443.
22. Blondel B, Zuber MC. Marital status and cohabitation during pregnancy:
relationship with social conditions, antenatal care and pregnancy outcome in
France. Paediatric and Perinatal Epidemiology. 1988;2:125–137.
23. Olsén P, Läära E, Rantakallio P, Järvelin M-R, Sarpola A, Hartikainen A-L.
years. American Journal of Epidemiology. 1995;142:1184–1193.
24. Pickering RM, Deeks JJ. Risks of delivery during the 20th to the 36th week of
gestation. International Journal of Epidemiology. 1991;20:456–466.
ponderal index and gestational age in Sweden in the 1920s and the 1980s. Acta
Paediatrica. 1999;88:445–453.
26. El-Sayed AM, Tracy M, Galea S. Life course variation in the relation between
Maternal marital status and preterm birth. Ann Epidemiol. 2012;22(3):168–174.
27. South S. Historical changes and life course variation in the determinants of
premarital childbearing. Journal of Marriage and the Family. 1999;61:752–763.
28. Remez L. Married mothers fare the best economically, even if they were unwed
at the time they gave birth. Family Planning Perspectives. 1999;31:258–259.
29. Bracher M, Santow G. Economic independence and union formation in Sweden.
Population Studies. 1998;52:275–294.
30. Hedegaard M, Henriksen TB, Sabroe S, Secher NJ. Psychological distress in
pregnancy and preterm delivery. British Medical Journal. 1993;307:234–239.
31. Nordentoft M, Lou HC, Hansen D, Nim J, Pryds O, Rubin P, et al. Intrauterine
growth retardation and premature delivery: the influence of maternal smoking
and psychosocial factors. American Journal of Public Health. 1996;86:347–354.
32. Hetherington E, Doktorchik C, Premji SS, McDonald SW, Tough SC, Sauve RS.
Preterm birth and social support during pregnancy: a systematic review and
meta-analysis. Paediatr Perinat Epidemiol. 2015;29(6):523–535.
33. Shah PS, Zao J, Ali S. Maternal marital status and birth outcomes: a systematic
Reclamă Psih 64(1)0104
review and meta-analyses. Matern Child Health J. 2010;15:1097–1109.
34. Mong JA, Baker FC, Mahoney MM, Paul KN, Schwartz MD, Semba K, Silver
R. Sleep, rhythms, and the endocrine brain: influence of sex and gonadal
hormones. J Neurosci. 2011;31(45):16107–16116.
35. Von Ehrenstein OS, Wilhelm M, Wang A, Ritz B. Preterm birth and prenatal
maternal occupation: the role of hispanic ethnicity and nativity in a population-
based sample in Los Angeles, California. Am J Public Health. 2014;104(S1):S65–S72.
36. Saurel-Cubizolles MJ, Zeitlin J, Lelong N, Papiernik E, Di Renzo GC, Bréart
G, Group, Europop. Employment, working conditions, and preterm birth:
results from the Europop case-control survey. J Epidemiol Community Health.
2004;58(5):395–401.
Anul XVI • Nr. 64 (1/2021)
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 case report
Psychiatric psychopathology
in the context of multiple
sclerosis – diagnostic and
therapeutic challenges
Cristian Petrescu1, Abstract
Gabriela Marian1,2,
Cristian Traian The case report describes a complex clinical context of
a 24-year-old patient with multiple hospitalizations
Sima1, Carmen in psychiatric hospitals for psychotic symptoms and
Diana Dumitru1, behavioural disorders associated with neurodegenerative
Brîndușa Ecaterina pathology. The nosological classification and the
Focșeneanu1,2 temporal association with the onset of multiple
1. “Prof. Dr. Alexandru Obregia”
sclerosis were both a clinical and a therapeutic
Clinical Hospital of Psychiatry, challenge, justifying a dynamic monitoring of the
Bucharest, Romania symptoms, using the history of MRI procedures and
2. Faculty of Medicine, current investigations for further information.
“Titu Maiorescu” University, Keywords: psychosis, mood lability, multiple sclerosis,
Bucharest, Romania
cognitive impairment
Corresponding author:
Brîndușa Ecaterina Focșeneanu
E-mail: brindusafocseneanu@
yahoo.com
Recieved:
01.02.2021 Aspecte de psihopatologie în contextul sclerozei multiple – provocare
Accepted:
25.02.2021 diagnostică și terapeutică
Suggested citation for this article: Petrescu C, Marian G, Sima CT, Dumitru CD, Focșeneanu BE. Psychiatric psychopathology in the context of multiple sclerosis –
diagnostic and therapeutic challenges. Psihiatru.ro. 2021;64(1):22-25
Case presentation
The patient A.B. (24 years old, female), known with a
neuropsychiatric history of multiple decompensations
and hospitalizations in the last 12 months, is brought
to the emergency room of the “Prof. Dr. Alexandru
Obregia” Clinical Psychiatric Hospital by the ambu-
lance and the police, at the request of her family, for
a psychopathological symptomatology dominated by
psychomotor agitation, bizarre psychotic modified
behaviour, unsystematic delusional ideas of persecu-
tion, low frustration tolerance, and suicide threats.
The patient lives alone in an apartment owned by
the family, she is unmarried, a high school graduate,
but unable to complete the first year of college after
several attempts. The patient had to make great ef-
forts to recover two years of education in one year
when she moved to Canada. Family relationships are
strained, dominated by verbal aggression and episodes
of physical aggression. The patient spends a lot of
time on social networks, constantly posting images
of herself in various poses, which can be translated
as behavioural disinhibition.
According to family reports, the patient experienced
a psychotraumatic event at the age of 17 years old,
being the victim of a sexual assault. The patient has
22
Rezumat
Cazul prezentat descrie un tablou clinic complex la o
pacientă de 24 de ani, cu multiple internări în spitale
de psihiatrie pentru simptomatologie psihotică și
tulburări de comportament asociate unei patologii
neurodegenerative. Încadrarea nosologică și asocierea
temporală cu debutul sclerozei multiple au constituit o
provocare atât clinică, cât și terapeutică, justificând o
monitorizare în dinamică a simptomatologiei, utilizarea
istoricului imagistic RMN și investigații curente pentru
obţinerea de informații.
Cuvinte-cheie: psihoză, labilitate afectivă, scleroză
multiplă, tulburări cognitive
been a smoker since the age of 14, she drinks coffee,
and occasionally consumes alcohol and psychoactive
substances.
Personal history
At the age of 21 years old, she was diagnosed with
recurrent-remissive multiple sclerosis (RR), stating
that the disease began with ocular symptoms (optic
neuritis of the right eye), with diplopia, scotomas and
pain with eye movements. The patient was treated
for a year with interferon and methylprednisolone
intravenously (i.v).
The patient refused the recommended treatment, due
to multiple side effects, preferring the administration
of an alternative treatment of her choice with 50,000
IU of vitamin D3 per day, initially, then the same dose
weekly. In this decision, she was supported by her
parents, against the medical advice.
Psychiatric history
The first admission to a psychiatric service took
place three years ago in Canada, before the diagnosis
of the neurological condition, for a suicide attempt
in the context of a depressive episode with psychotic
elements (“My voices told me to throw myself over the
Anul XVI • Nr. 64 (1/2021)

window, that God will hold me in his arms”) for which
she received treatment with quetiapine 100 mg/day
and escitalopram 10 mg/day, with a good evolution,
but she interrupted the treatment after a few months.
Before the onset, behavioural changes secondary to
traumatic emotional relationships were reported,
with dysphoric crises, philosophical and religious
preoccupations uncharacteristic for her personality,
going as far as conversion to another religion (Muslim).
Two years later, she was hospitalized as an emer-
gency at the “Prof. Dr. Alexandru Obregia” Clinical
Hospital of Psychiatry for a psychopathological symp-
tomatology dominated by auditory hallucinations,
depressed mood, emotional lability, inappropriate
affect towards the father and social withdrawal. She
received treatment with olanzapine 5 mg/day, escit-
alopram 10 mg/‌d ay and gabapentin 300 mg/day, with
the incomplete remission of symptoms.
She was re-hospitalized after seven months for
psychomotor anxiety, bizarre psychotic behaviour
modification, ideoverbal dissociation, persecutory
delusion, ideas of reference, affective ambivalence
and inappropriate affect towards the family, irasci-
bility and irritability. She received treatment with
olanzapine 7.5 mg/day with the same nonadherence
at home, being required to be readmitted three weeks
after her discharge from the hospital.
Somatic examination
The medical assessment reveals a BMI of 16.9, with
vital signs within normal limits and no motor deficits
at the time of admission. On the dorsal side of the
hands, bilaterally, the skin has erythematous and
scratchy lesions secondary to excessive use of disin-
fectants and due to dehydration.
Mental status assessment
The patient is time/place/person oriented; the phy-
sician-patient contact is relatively difficult to achieve
due to the patient’s hostility towards certain subjects
and her fear of a negative evaluation, and the visual
contact is made and maintained during the course of
the interview. The facial expressiveness is in accord-
ance with the verbal and affective content transmitted,
with theatrical, demonstrative and artificial notes.
No perceptual disturbances like hallucinations are
noted at the time of examination. Selective hyperpro-
sexia for hypochondriac themes and focused on the
dysfunctional relationship with her father, along with
spontaneous hypoprosexia, moderate-severe hypo­
mnesia with the inability to complete complex tasks,
hypermnesia for certain thematic evocations with
psychotic content. In the sphere of thinking, there is
a slightly accelerated rhythm of ideas, with the main
interest reduced to a few topics aimed towards health,
the obsessive aspect of her body shape, preoccupation
with evil religious symbols, and suspiciousness. In
terms of thinking impairments, there are delusional
ideas of persecution, prejudice, reference and with
Anul XVI • Nr. 64 (1/2021)
psihiatru
mystical characteristics. Spontaneous speech is pre-
sent, circumstantiality used to conceal deficit, with
a tendency to disorganize under the action of minor
stress and lack of cause-effect relationship in the pa-
tient’s explanations. The patient’s way of thinking is
dominated by distractibility, illogical statements and
tangentiality. The verbal rhythm is uneven, with peri-
ods of acceleration and verbal outbursts, alternating
with periods of mental depletion, lack of concentration
and verbal stereotypes. The mood is dysphoric, the
patient is short-tempered, has inappropriate feelings
towards her father, emotional lability, demonstrative
behaviour, aggressive outbursts, rapid action without
deliberation and by that sacrificing critical thinking,
impulsivity, irritability, social withdrawal, reduced
level of activity, lack of interests, odd way of acting
(she shaved the hair in the frontal region to lengthen
the oval of her face, she colored the sides of her neck
with black eyeshadow to thin her neck appearance,
she asked for paper bags to constantly carry makeup,
cigarettes and disinfectants). Self-esteem is inflated,
she establishes superficial relationships with others,
she has erotic disinhibition, suggestibility, motiva-
tional ambivalence, lowered ability to make decisions
or to act (hypobulia), apathy, reduced planning of her
future, lack of organization, activity sequencing, and
reduced abstract thinking. She avoids oral treatment
by trying to disguise the administration methods
(pills); food instinct and conservation instinct are
decreased.
Paraclinical examinations
ECG: normal.
n
MDT-dip card toxicology: negative.
n
HCG pregnancy test: negative
n
Total serum vitamin D: 215.84 ng/ml (optimal:
n
30-100 ng/ml).
Biochemistry: within normal limits; normal com-
n
plete blood count; FT3, FT4, TSH: within normal
limits.
Ag HBs negative, anti-HCV negative.
n
Urinalysis within normal limits.
n
Medical imaging
Cerebral and cervical vertebra-medullary contrast-
enhanced MRI i.v. 3T, performed in 2017, reveals mul-
tiple infracentimetric lesions located at the following
levels: right cerebellar, subcortical, bilateral perive-
ntricular, parieto-occipital subcortical left, frontal
left, and a lesion of 9.4 mm in the posterolateral cords
C3 segment, non-gadolinium enhancing lesions and
demyelination areas at the right optic nerve.
Contrast-enhanced brain MRI i.v., performed in
2019, reveals areas of demyelination in the brain stem
and in the left cerebellar hemisphere, non-gadolinium
enhancing lesions, along with multiple bilateral and
periventricular demyelination areas in the white mat-
ter of the cerebral hemispheres, as well as subcortical
lesions, one of 16 mm in the right parietal level and
23
case report
one of 5.6 mm in the left periventricular parietal level.
During hospitalization, the patient complained of
diplopia, postural instability, and tremor of the upper
limbs. The neurological exam revealed exacerbated
deep tendon reflexes in the left hemibody with posi-
tive left Hoffmann reflex, suggestive of a lesion in the
corticospinal tract.
I.v. contrast-enhanced brain MRI, performed during
the current hospitalization, reveals multiple demy-
elinating processes with similar distribution to the
previous example in 2019 sub- and supratentorial,
predominantly periventricular and at the cortico-
subcortical junction, affecting both edges of the corpus
callosum. Lesions in the dentate nucleus and middle
cerebellar peduncles, with lesions in the brainstem at
the origin of the right V-VII nerves. Multiple bilateral
frontal subcortical lacunar lesions.
The psychological examination highlights affective
and behavioural disorders, with affective instability,
irritability, disproportionate irascibility to the impor-
tance of psychosocial precipitating factor, marked
apathy, suspicion, paranoid interpretation, severe
attention deficit disorder, and short-term memory
disorders with altered solving of complex tasks.
Diagnosis motivation
Based on the anamnesis, the symptomatology,
the history of the disease, the examination of the
mental state (bizarre preoccupations, interrogative-
investigative disposition, tendencies to disorganized
thinking, social withdrawal, difficulties in main-
taining stable interpersonal relationships) and the
paraclinical investigations, the supported diagnosis
is: organic personality disorder, mixed type (labile
and paranoid); psychotic disorder due to multiple
sclerosis, with delusional ideas; mild neurocognitive
disorder (in research criteria according to DSM IV-TR,
but implemented in DSM-5).
Sustained diagnosis
For organic personality disorder, mixed type:
persistent personality disorder (marked affective
lability, delusional ideas of persecution, prejudice,
reference), representing a change in the previous
personality pattern; there is evidence that the disor-
der is the direct pathophysiological consequence of
a medical condition – multiple sclerosis (history of
brain damage, absence of insight of the phenomenol-
ogy as attributed to the medical condition, temporal
association with the onset or exacerbation of the
medical condition); the disorder does not manifest
itself exclusively during a delirium; the disorder causes
clinically significant discomfort and dysfunction in
the social and professional life.
For psychotic disorder due to multiple sclerosis,
with delusional ideas: prominent delusional ideas;
there is evidence that the disorder is the direct patho-
physiological consequence of a medical condition
(multiple sclerosis), the disorder does not manifest
24
itself exclusively during delirium, the disorder causes
significant clinical discomfort and dysfunction in
the social and professional fields, the disorder is not
better explained by another mental disorder (affec-
tive disorder with psychotic elements or endogenous
psychotic disorder), the symptoms evolving in close
correlation with the evolution of the neurological
disease (1,2).
For the mild neurocognitive disorder, second-
ary to a medical condition: the patient’s complex
attention is affected in such a way that she needs
more time than before in order to carry out her usual
tasks; an increased effort is required for performing
multiple-stage extensive projects, such as the faculty;
she mentioned being tired, as a result of the effort
needed for organizing, planning or decision making;
the learning and memory function was affected (the
patient has got difficulties in remembering the recent
events and she asks for pen and paper for making
lists of products needed for her personal care); she
has significant difficulties in finding her words; in
this case, the impact on her social resilience appears
under the form of decreased empathy, the increase
of the introvert behaviour, reduced inhibition and
apathy, withdrawal and social disregard(2).
Differential diagnosis
Other mental disorders, secondary to a medical
n
condition – the impairment could not be better
explained by any other mental disorder, caused by
the medical condition(2).
Substance or medicine-induced psychotic dis-
n
order: the change of personality appears neither
in the context of psychoactive substance or con-
sumption, nor in the context of the treatment with
corticosteroids (2).
The affective disorder with psychotic features
n
or endogenous psychotic disorder – the presence
of the etiopathological factor (multiple sclerosis).
Other personality disorders – a clinically sig-
n
nificant change is present, as compared to the
main personality (2), in the evolutive context of the
cerebral demyelination lesions.
Present treatment
Due to her unpredictability, her disorganized be-
haviour and her hetero- and autoaggressive poten-
tial, the patient was not voluntarily admitted in the
hospital, in compliance with the Law no. 487/2002.
The main objectives consisted in improving the deliri-
ous symptomatology, as well as proper feeding and
hydrating needed for preventing weight loss and the
other potential hydroelectrolytic and protein caloric
imbalances.
The pharmacological treatment consisted in pre-
scribing antipsychotics, such as zuclopenthixol 1 vial.
i.m., three doses; the reason was the noncompliance
with the oral medication and the need to eliminate
the conceptual-behavioural disorganization, the
Anul XVI • Nr. 64 (1/2021)

agitation and the delirious ideas; at a later stage, the
treatment with olanzapine 10 mg/day and amisulpride
200 mg/‌day was started, but the latter was interrupted,
due to the induced hyperprolactinaemia (288 ng/mL),
mood stabilizer with pregabalin 225 mg/day, vitamins
and hydroelectrolytical rebalancing.
Evolution
Throughout the admission period of 39 days, the
evolution was slightly favourable, the patient becom-
ing cooperative and adherent to the therapeutic plan.
A significant improvement of the delirious picture,
present upon admission into hospital, was noted;
however, there were a reduced persistence of the ste-
reotypes, steril behaviour and cognitive deterioration.
Prognosis
Considering the remissive status of the present
neurological condition, of the partial insight on the
psychotic changes and the experiencing of the dys-
phoric mood, with explosive behaviour, the prognosis
is favourable in the short term. However, the prognosis
is unfavourable in the long term, based on the history
of treatment noncompliance for both conditions, the
precarious emotional support, due to the family con-
flicts, the disruption of the patient’s social interests,
the unpredictability of the multiple sclerosis evolution
and the association of the frontally localized ischemic
vascular lesions (frontal dysexecutive syndrome).
Another factor of negative prognosis is the suicidal
risk, the multiple sclerosis being associated with a
suicide risk twice as high as in the general population,
especially for those in which the disease appears under
30 years old(3,4); the patient already had an attempt
in her past record.
Discussion
The appearance of the psychotic episodes within
the context of multiple sclerosis is documented in
the specialty literature. The question is whether an
endogenous or exogenous organic cause may be the
basis of this change of personality structure and the
emergence of the psychotic episode. Considering the
multiple lesions and their localization at the cerebral
and cerebellar levels, we believe that these lesions
may be the basis of the delirious ideation of persecu-
tion, self-overevaluation, passive behaviour, lack of
criticism etc. According to the studies performed
until now, around 25% of the patients diagnosed
with multiple sclerosis were admitted within the
psychiatric service (ambulatory or hospital), at
the time or after the beginning of the neurological
symptomatology (5) .
The possibility of a psychotic episode occurrence in
the case of patients suffering from multiple sclerosis
is three times higher than in the case of the general
population(6). A study made on a lot of 10,000 patients
suffering from multiple sclerosis has shown the appear-
ance of at least one psychotic episode in 4% of them(7).
Anul XVI • Nr. 64 (1/2021)
psihiatru
Sixty percent of the patients suffering from multiple
sclerosis and psychotic episodes have frontotemporal
lesions. Among the patients suffering from multiple
sclerosis and a severe psychotic episode, 87% have
delirious ideation of persecution, 80% have lack of
fear, and 53% have reference ideas. The presence
of periventricular lesions can be at the basis of the
psychotic episode (8).
When the demyelinising process is affecting the
temporal lobe and the diencephalic regions, memory
imbalances may appear. These have a prevalence of
40-60% of the patients and the characteristic feature
is the fact that the short-term memory is affected.
About 50% of the patients have moderate cognitive
disorders, which are apparently not linked to the se-
verity of the neurological symptoms or the duration
of disease evolution. The depressive episodes are more
common than the euphoric or hypomanic states (25-
50% compared to 10%), thus explaining the increased
suicidal risk. Personality disorders are frequent in
the context of multiple sclerosis, therefore 40% of
the patients are affected by changes related mainly
to irritability and social withdrawal(5).
Conclusions
The diagnosis of organic mental disorder involves a
process which is often difficult; on one side, a skilful
use of the sequentially performed psychiatric inter-
view is needed, both with the patient, and with the
people who might provide credible information. On
the other hand, a thorough psychological examination
is also needed, for covering both the cognitive and the
affective-relational sides of the personality, and also a
targeted dynamic psychopharmacologic interventions.
These are completed by complementary paraclinical
checkups, used to certify the correlation between the
organicity and the psychiatric symptomatology (9). n
References
1. DSM IV-TR. Manual de diagnostic și statistică a tulburărilor mintale, ediţia a patra
revizuită, Bucuresti, 2003, Asociaţia Psihiatrilor Liberi din România p.188-190;
334-338; 764.
2. DSM-5. Manual de Diagnostic și Clasificare Statistică a Tulburărilor Mintale,
American Psychiatric Association, Editura Callisto, 2016, p593-595,645, 707.
3. Brønnum-Hansen H, Stenager E, Nylev Stenager E, et al Suicide among
Danes with multiple sclerosis. Journal of Neurology, Neurosurgery & Psychiatry.
2005;76:1457-1459.
4. Sadock BJ, Sadock VA, Pedro Ruiz P. Kaplan & Sadock’s synopsis of psychiatry:
behavioral sciences/clinical psychiatry. 11th ed. Philadelphia: Lippincott Williams
& Wilkins, 2015; p. 720, 728.
5. Stenager EN, Stenager E, Koch-Henriksen N, Brønnum-Hansen H, Hyllested
K, Jensen K, Bille-Brahe U. Suicide and multiple sclerosis: an epidemiological
investigation. J Neurol Neurosurg Psychiatry. 1992;55:542-545.
6. Gilberthorpe TG, O’Connell KE, Carolan A, et al. The spectrum of psychosis in
multiple sclerosis: a clinical case series. Neuropsychiatr Dis Treat. 2017;13:303-318.
7. Patten SB, Svenson LW, Metz LM, Psychotic disorders in MS: Population-based
evidence of an association. Neurology. 2005 Oct;65 (7):1123-1125.
8. Camara-Lemarroy CR, Ibarra-Yruegas BE, Rodriguez-Gutierrez R, Berrios-Morales
I, Ionete C, Riskind P. The varieties of psychosis in multiple sclerosis: A systematic
review of cases. Multiple Sclerosis and Related Disorders. 2017 Feb;12:9-14.
9. Trifu S, Marian G, Uță A. Tulburarea organică de personalitate – aspecte clinice
și elemente de diagnostic diferențial. Lucrare prezentată în cadrul celui de-al
III-lea Congres dedicat Cercetării Științifice Psihiatrice din România, Oradea,
România, 2013.
25
 research

Inpatient psychiatric services

Doina Cozman1,2,
Bogdan Nemeș1,2,
Andrei Buciuta1,2,
Claudia Dima3,
Roxana Stoean2,4
1. "Iuliu Hațieganu" University of
Medicine and Pharmacy ,
Cluj-Napoca, Romania
2. Romanian Association of
Psychiatry and Psychotherapy
3. Romanian Institute
of Public Health
4. "Carol Davila" University
of Medicine and Pharmacy,
Bucharest, Romania
Corresponding author:
Bogdan Nemeș
E-mail: bmnemes@gmail.com
use during the COVID-19
pandemic in Romania
Abstract
The distribution by macroregions of human resources and
of the institutional treatment capacities for psychiatric
disorders is uneven, which led to a very low supply of
support services for psychiatric pathology during the study
period. The distribution of human resource of psychiatrists
in Romania is 11.88/100,000 inhabitants, far behind
most European countries. Moreover, in some Romanian
macroregions (2 and 4), the number of psychiatrists per
100,000 inhabitants is below the national average. A
situation below the average level of distribution of human
resources and hospital beds was found in Macroregion 2
and Macroregion 3. The hospitalization indicators were
influenced by the conditions imposed by the state of
emergency, respectively by the state of alert induced by
evolution of the COVID-19 pandemic, throughout the year
2020. Thus, the most obvious changes of the diagnostic
related groups (DRG) indicators in 2020 versus 2019 were: the
decrease in the number of patients with affective disorders
hospitalized in public hospitals; the increase in the duration
of hospitalization of patients, as a proof of the severity of
hospitalized cases. By the regulations of the Government
Ordinance no. 252/20.03.2020, regarding the telemedicine
consultations and, implicitly, the telepsychiatric ones, the
discrepancy between the increased demand for psychiatric
assistance and the much-diminished offer for access to
hospitalizations or consultations in Romania was reduced.
Keywords: macroregions, number of psychiatrists/100 000
inhabitants, number of hospital beds/100 000 inhabitants,
hospitalization indicators, telepsychiatry
Rezumat
Distribuția în cele patru macroregiuni ale României a
resurselor umane și a capacităţilor instituționale de
internare pentru tratamentul tulburărilor psihiatrice
este inegală. Distribuţia resursei umane de psihiatri
din România este de 11,88/100000 de locuitori, mult în
urma majorității țărilor europene. Mai mult, în unele
macroregiuni din România (2 și 4), numărul psihiatrilor
la 100000 de locuitori se situează sub media pe țară.
Această situație este și mai evidentă în Macroregiunea
2 și Macroregiunea 3, unde se găsește cel mai scăzut
număr mediu de resurse umane și de paturi de spital
la 100000 de locuitori. Indicatorii de spitalizare pe
parcursul anului 2020 au fost influențați de condițiile
impuse de starea de urgență, urmată de cea de alertă,
și de gradul de evoluție a pandemiei de COVID-19.
Astfel, cele mai evidente schimbări a indicatorilor DRG
de spitalizare în 2020 în comparație cu cei din 2019 au
fost reprezentate de: scăderea numărului de pacienți cu
tulburări afective internați în spitalele publice; creșterea
duratei de spitalizare a pacienților, ca dovadă a severității
cazurilor internate. Prin reglementările aduse de OUG
252/20.03.2020, în privința consultațiilor de telemedicină,
inclusiv de telepsihiatrie, discrepanțele dintre cererea
crescută de asistență psihiatrică și oferta mult dimininuată
de acces la îngrijirile spitalicești și/sau la consultațiile în
ambulatoriu s-au redus.
Cuvinte-cheie: macroregiuni, număr de psihiatri/100 000
de locuitori, număr de paturi/100 000 de locuitori, indicatori
de spitalizare, telepsihiatrie

Recieved:
01.02.2021 Adresabilitatea către serviciile spitaliceşti de psihiatrie în timpul pandemiei
Accepted:
25.02.2021 de COVID-19 din România
Suggested citation for this article: Cozman D, Nemeș B, Buciuta A, Dima C, Stoean R. Inpatients psychiatric services use during the COVID-19 pandemic in Romania.
Psihiatru.ro. 2021;64(1):26-31

It is well known that epidemics can be the basis for
new psychiatric pathologies or relapses in patients
with an already established psychiatric diagnosis (1).
Thus, during and also after the pandemic, the mental
health needs are increasing, which can overload the
available resources, the most problematic being the
areas where access is limited due to poor medical in-
frastructure or insufficient specialized medical staff.
Since the beginning of March 2020 (11.03.2020, the
date of declaration of COVID-19 as a pandemic, in-
cluding in the EU and, implicitly, in Romania), there
has been an increase in request for medical care from
patients in hospital outpatient clinics and emergency
receptions. This change corresponded with an increase
in presentations related to depressive symptoms.
The declaration of the state of emergency by De-
cree of the President of Romania no. 195 of March
16, 2020, regarding the establishment of the state of
emergency on the Romanian territory (2), opened the
possibility of issuing military ordinances. Thus, the
Military Ordinance no. 2 of 21.03.2020 provided for
the restriction of the movement of persons between
10 p.m. and 6 a.m.
On 23.03.2020, by Order no. 74527 of the Department
for Emergency Situations, the Romanian state decided
that the activity in the hospital outpatient services

26 Anul XVI • Nr. 64 (1/2021)

 psihiatru

be suspended for all consultations and treatments Research methodology

that can be rescheduled. Due to the large number Research typology
of patients requesting outpatient medical services, This study is retrospective, observational and de-
consultations in the hospital emergency room had to scriptive.
supplement this type of consultation. Thus, a larger
number of patients presented to the emergency rooms Study population
which did not require emergency psychiatric care. The sufficient number of specialists is an important
At the express request of some professional medi- criterion for assessing the degree of access of the popu-
cal organizations, including that of psychiatrists, lation to care for mental disorders. In this regard, the
represented by the Romanian Association of Psychia- delimitations on the EU territory of the geographical and
try and Psychotherapy, the Government responded socioeconomic regions, called macroregions (MR), are
promptly by issuing the Government Ordinance no. helpful. Thus, in Romania there are described geographi-
252/30.03.2020, which decided to allow telemedicine cally four macroregions: Macroregion 1 (MR 1 – 4.879
consultations (implicitly those of telepsychiatry) in million inhabitants), Macroregion 2 (MR 2 – 5.620 mil-
the outpatient network (3). lion inhabitants), Macroregion 3 (MR 3 – 5.256 million
The Order of the Minister of Health no. 555, in force since inhabitants) and Macroregion 4 (MR 4 – 3.720 million
7.04 2020, on the approval of the plan of measures for the inhabitants), according to the Romanian National In-
preparation of hospitals in the context of the COVID-19 stitute of Statistics (NIS)(5). The most relevant socioeco-
epidemic, of the list of hospitals providing healthcare to nomic indicators are GDP/capita and unemployment
patients tested positive for SARS-CoV-2 in phase I and rate (Table 1).
in phase II and the list of support hospitals for patients The highest number of inhabitants was found in
tested positive or suspected with SARS-CoV-2 infection, MR 2 (5.620 million inhabitants). Unfortunately, the
imposed the epidemiological triage at hospitalization or same MR 2 is the macroregion with the lowest socio-
consultation at the level of the emergency unit (or emer- economic profile.
gency room) of each hospital, regardless of specialty(4).
Until Government Ordinance no. 252/30.03.2020, for
people returning to the country, the only possibility to
care for a psychiatric condition was to call for consulta-
tions in the private system or to the emergency room
of psychiatric hospitals. In these circumstances, the
problem of access to mental healthcare has become
acute, which in our country is still limited by some
barriers (structural or attitudinal), such as:
n unequal distribution of hospital beds in different
geographical areas;
n long distances from the hospital or the outpatient
clinic;
n unequal distribution of human resources for the care
of mental disorders throughout the country;
n deficient information regarding the availability of
psychiatric outpatient clinics;
n difficulties in scheduling consultations;
n problems with the operating hours of outpatient clinics
(especially for those over 65 years of age);
n attitudinal barriers (stigma, opposition to psychiatric
consultation, poor relationship with medical staff etc.). Figure 1. Map of Romania and its position in Europe

Table 1 Demographic and socioeconomic characteristics of the macroregions of Romania

Macroregion Inhabitants (milion) GDP/capita (PPS) Unemployment rate (%)
MR 1 4.879 49.36 2.3
MR 2 5.620 40.19 4.2
MR 3 5.256 86.73 2.1
MR 4 3.720 48.37 3.4
*PPS – Purchasing power standards

Anul XVI • Nr. 64 (1/2021)

27
research
Sources of information
Four categories of unclassified national and inter-
national sources of public data were used:
a. Demographic data.
b. Epidemiological information on the evolution of
the COVID-19 pandemic in Romania.
c. I nformation about the beds in the public psychi-
atric care institutions.
d. I nformation about the human resource, represent-
ed by the specialized doctors of adult psychiatry
and child psychiatry (the other staff working in
the assistance institutions for people with mental
issues was not taken into account, due to the lack
of official data for this sector).
Demographic data were taken from two sources:
✔  National Institute of Statistics, for the total pop-
ulation of Romania and the population of the
counties(5);
✔  for the geographical delimitation of the four ter-
ritorial units – macroregions (MR) of Romania
located in the EC nomenclature, we used the data
published in EUROSTAT(6)
For the information about the evolution of the
COVID-19 pandemic in Romania, we used the data
published daily by the National Institute of Public
Health (NIPH)(7).
The absolute number of beds in psychiatric institu-
tions in the public system (acute psychiatry, chronic
psychiatry, child psychiatry, drug addiction depart-
ments) in each county was provided by the National
Center for Mental Health and Anti-Drug Control
(NCMHA)(8).
The human resource available for providing psy-
chiatric treatment, represented by the number of
psychiatrists in public hospitals, doctors in specialized
clinics (public and private), was taken from the Na-
tional Health Insurance House (NHIH) and NCMHA (8).
14
12.21
11.76
12
10
8.4 8.07
8
6
0
MR1 MR3
Hospital seng Outpaent seng
Figure 2. Coverage of the macroregions in Romania with psychiatrists per 100,000 inhabitants (2018)
28
Statistical analysis
The statistical calculations were performed using
Microsoft Office Excel, version 2019.
Thus, we calculated the distribution of the popula-
tion by macroregions, the epidemiological indicators of
­COVID-19 infection per 100,000 inhabitants, the number
of doctors working in hospitals and those working in
outpatient clinics, in both situations the reporting being
done per 100,000 inhabitants, and the number of beds in
psychiatric institutions, both public and private, reported
per 100,000 inhabitants.
The average of the hospitalization indicators was
calculated according to the quarters (Q). These indica-
tors include: the number of hospitalizations, the average
duration of hospitalization, and the total number of days
of hospitalization associated with the major diagnostic
group.
Results
A. Distribution by macroregions of psychiatrists
in Romania
The coverage of mental healthcare services, repre-
sented by the mean number of psychiatrists working
in hospitals and outpatient clinics, is 11.88 per 100,000
inhabitants (EUROSTAT, 2018). This number is larger
than 10 years ago, which was of 10 psychiatrists per
100,000 inhabitants.
But this number is different in the four macroregions
of Romania. The number of psychiatrists in each mac-
roregion and their distribution per 100,000 inhabitants
in 2018 are presented in Table 2 and Figure 2.
We found that in MR 1, an optimal number of psy-
chiatrists is ensured, both in the hospital services
and in the coverage with norms of the NHIH affili-
ated outpatient clinics. On the other hand, there is
a shortage of human resources for psychiatric care
(hospital/outpatient) in MR 2.
11.4
10.69
7.61
5.73
MR4 MR2
Hospital seng Outpaent seng
Anul XVI • Nr. 64 (1/2021)
 psihiatru

Table 2
Distribution by macroregions C. Psychiatric care during the restrictions
of psychiatrists in Romania imposed by the emergency/alert state declared
due to the COVID-19 pandemic (2020)
Psychiatrists in hospitals Psychiatrist in outpatient clinics The impact of the pandemic on psychiatric care
Regions
NP (NP/100,000) NP (NP/100,000) in Romania can be assessed by the dynamics of hos-
MR 1 585 (12.21) 410 (8.40) pitalization indicators of one of the most common
MR 2 513 (10.69) 322 (5.72) mental disorders of modern times, namely major
MR 3 641 (11.75) 424 (8.08) affective disorder.
MR 4 506 (11.39) 283 (7.60) In this respect, the year 2020 was taken into account,
Total 2245 (11.49) 1439 (7.39) during which it was possible to notice a change in all
MR – macroregion, NP – no. of psychiatrists hospitalization indicators, regarding the hospitali-
zations in public psychiatric hospitals compared to
B. Distribution by macroregions of the number the same data from 2019 (Figure 3 and Figure 4). The
of psychiatric beds in the public system, by indicators taken into account were: number of hos-
categories of care pitalizations, average length of hospitalization, total
The number of beds in the acute wards is almost number of hospitalization days. The hospitalization
equal in MR 2 (2016) and MR 3 (2006), but with a sig- indicators for affective disorders in public hospitals
nificant decrease in MR 4 (1138). On the other hand, (2020 versus 2019) were calculated by age groups:
MR 4 has the highest number of beds in the long-term patients under 70 years old, respectively patients
wards (2330), while MR 3 (1268) has the fewest in this over 69 years old.
category. A disadvantageous situation is the insuffi- In the age group below 70 years old, there was a
cient number of beds for the treatment of addiction drastic decrease in the number of hospitalizations
pathology, with a total number in the whole country and in the total number of hospitalization days, but
of only 193 beds. Also, the beds for child psychiatry the average duration of hospitalizations increased,
are poorly represented in the country (457) – Table 3(8). especially in Q4 (by 50%).

Q1 Q2 Q3 Q4 Total Q1-Q4
60%

40%

20%

0%

-20%

-40%

-60%

-80%
Admissions Hospitalizaon days ALOS
*Q = Quarter; **ALOS = Average Length of Stay

Figure 3. Indicators of hospitalization in public psychiatric hospitals for major affective disorders (below 70 years old) for
2020 compared with 2019

Table 3 Distribution by MR of the number of beds in psychiatric hospitals (public sector)

Total no. of beds Acute care Addiction care Long-term care Pediatric care
Region
n (n/100,000 pop) n (n/100,000) n(n/100,000) n(n/100,000) n(n/100,000)
MR 1 4465 (91.50) 1914 (48.64) 29 (0.73) 2398 (60.94) 124 (1.31)
MR 2 4170 (74.19) 2016 (45.14) 70 (1.56) 1964 (43.97) 120 (1.04)
MR 3 3479 (68.18) 2006 (46.35) 94 (2.17) 1268 (29.30) 111 (1.19)
MR 4 3570 (95.96) 1138 (36.95) 0 (0) 2330 (75.67) 102 (1.59)
Total 15684 (80.52) 7074 (44.75) 193 (1.22) 7960(50.35) 457 (1.24)
MR – macroregions, n – no. of beds (source: https://e-psihiatrie.ro/raspunsurile-cnas-si-cnsmla-cu-privire-la-harta-serviciilor-de-psihiatrie-din-romania/)

Anul XVI • Nr. 64 (1/2021)

29
research
Q1 Q2
20%
10%
0%
-10%
-20%
-30%
-40%
-50%
-60%
-70%
-80%
Admissions
*Q = Quarter; **ALOS = Average Length of Stay
Figure 4. Indicators of hospitalization in public psychiatric hospitals for major affective disorders (above 69 years old) for
2020 compared with 2019
In the age group above 69 years old, an even more
drastic decrease was observed in the number of hos-
pitalizations (more than 70%), followed closely by the
decrease in the number of days of hospitalization.
The length of hospitalization increased on average
by 15% throughout 2020.
Discussion
The distribution by macroregions of human resources
and institutional treatment capacities for psychiatric
disorders is uneven, both in terms of human resources
(psychiatrists for adults and children) and in terms
of the logistical resource of coverage with psychiatric
beds, differentiated in hospitals on different categories
of pathology (acute or chronic psychiatric disorders,
addictions) or age (child psychiatry, psychogeriatrics).
A. The distribution by macroregions of psychiatrists
in Romania shows that MR 1 is the one that offers
the best coverage in terms of psychiatrists, both in
hospitals (12.21 psychiatrists per 100,000 inhabitants)
and outpatient clinics (8.4 psychiatrists per 100,000
inhabitants), followed by MR 2 (12.21 psychiatrists in
hospitals per 100,000 inhabitants and 8.07 psychia-
trists in outpatient clinics) and MR 4 (11.40 psychia-
trists in hospitals per 100,000 inhabitants and 7.61
in outpatient facilities). Macroregion 2 is the one
that offers the lowest coverage of psychiatrists both
in hospitals (10.69 psychiatrists per 100,000 inhabit-
ants) and in outpatient clinics (5.73 psychiatrists per
100,000 inhabitants). We also refer to the precarious
economic conditions of the Macroregion 2.
However, the number of psychiatrists in Roma-
nia (11.88/100,000 inhabitants) compared to coun-
tries such as Switzerland (53.1/100,000), Germany
(27.75/100,000), The Netherlands (24.15/100,000) or
Greece (25.79/100,000), is much lower.
30
Q3 Q4 Total Q1-Q4
Hospitalizaon days ALOS
B. The distribution of the number of beds within
psychiatric institutions varies in the macroregions
of Romania, MR 4 having the highest number of beds
per 100,000 inhabitants (95.96/100,000 inhabitants),
followed by MR 1 (91.5 beds per 100,000 inhabitants)
and MR 2 (74.19/100,000 inhabitants). MR 3 has the
lowest total number of beds (68.18/100,000 inhabit-
ants). We could not correlate this low number of beds
in MR 3 with the economic conditions of Macroregion
3. Probably, most psychiatric institutes are concen-
trated in the capital of Romania and the neighboring
county (Ilfov).
The same ranking is maintained in terms of the
total number of psychiatric beds in chronic wards
per 100,000 inhabitants. It should be noted, however,
that there are very large inequalities between the
number of beds per 100,000 inhabitants between MR 4
(75.6/100,000 inhabitants) and MR 1 (60.94/100.000
inhabitants), on the one hand, and MR 2 (43.97/100,000
inhabitants) and MR 3 (29.3/100.000 inhabitants), on
the other hand.
MR 1 has the highest total number of psychiatric
beds in acute wards, 48.64/100,000 inhabitants, fol-
lowed by MR 3 (46.35/100,000 inhabitants), MR 2
(45.14/100,000 inhabitants) and MR 4 (36.95/100,000
inhabitants).
All macroregions have an almost similar number of
total child psychiatry beds per 100,000 inhabitants.
Regarding the total number of beds in addiction
wards per 100,000 inhabitants, in MR 4 there are none
and in the other macroregions the number is very small
(MR 1: 0.73/100,000 inhabitants; MR 2: 1.56/100,000
inhabitants; MR 3: 2.17/100.000 inhabitants).
Regarding the ratio between the number of psychi-
atric beds per 100,000 inhabitants in acute wards and
that of beds in chronic wards, it can be noticed that
Anul XVI • Nr. 64 (1/2021)

in MR 4 the ratio of the number of beds in chronic
wards is more than twice as high as in that of the
beds in the acute wards, while in MR 3 the number of
beds in the acute wards (46.35/100,000 inhabitants)
is much higher than that of the beds in the chronic
wards (29.3/100,000 inhabitants).
C. Hospitalization indicators regarding affective
major disorders highlighted the impact of the pan-
demic on the psychiatric care in Romania.
This impact was evaluated in the present study
only on a very common psychiatric pathology, namely
major affective disorders.
We notice that, if at the beginning of 2020, when the
COVID-19 pandemic had just started in Romania, the
indicators did not change significantly compared to
the same period (Quarter 1) of 2019, in the next three
quarters the DRG indicators changed drastically. The
measure of the transformation of some psychiatric
hospitals in Romania into COVID-19 support hospitals
was reflected in a differentiation regarding two DRG
indicators, compared to 2019: the number of hospi-
talized patients, and the number of hospitalization
days. The largest differences for the population below
70 years old were found in Quarter 2 and Quarter 4,
coinciding with the first and second waves of the
COVID-19 pandemic, respectively.
For the population above 69 years old, there were
accentuated the differences of the hospitalization
indicators, especially regarding the number of hos-
pitalizations, with decreases between 50% and 70%,
starting with Quarter 2.
The Average Length of Stay (ALOS) also increased
during Q2-Q4, especially regarding the patients ad-
mitted to chronic wards.
Study limits
Since we used demographic data (total and regional
number of the Romanian population) and data regard-
ing staff resources (from hospitals, outpatient clinics,
mental health centers) in the statistics for 2018, there
may be some differences from the statistical data for
2020. Unfortunately, these data have not been com-
municated so far, both in national and international
statistics.
Anul XVI • Nr. 64 (1/2021)
psihiatru
Conclusions
The distribution by macroregions of human re-
sources and institutional treatment capacities for
psychiatric disorders is uneven, which led to a very
low supply of support services for psychiatric pathol-
ogy during the study period.
The human resource of psychiatrists in Romania is
11.88/100,000, far behind most European countries.
Moreover, in some macroregions (MR 2 and MR 4),
the number of psychiatrists at 100,000 inhabitants
is below the national average.
A situation below the average level of distribution
of human resources and hospital beds was found in
MR 2 and MR 3.
The hospitalization indicators were influenced by the
conditions induced by the state of emergency, respec-
tively by the alert state imposed by the evolution of the
COVID-19 pandemic, throughout the year 2020. Thus, the
most obvious changes of the diagnostic related groups
(DRG) indicators in 2020 versus 2019 were:
n the decrease in the number of patients with affective
disorders hospitalized in public hospitals;
n the increase in the duration of hospitalization of pa-
tients, as a proof of the severity of hospitalized cases.
This change in DRG indicators in 2020 can be also
explained by the reduced possibility of the popula-
tion in areas with low socioeconomic indicators, for
using private services. The Government Ordinance
no. 252/20.03.2020 regulated the telemedicine con-
sultations – and, implicitly, the telepsychiatric ones
–, and the discrepancy between the increased demand
for psychiatric assistance and the much-diminished
offer for access to hospitalizations or consultations
in Romania was reduced. n
References
1. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The
forgotten plague: psychiatric manifestations of Ebola, Zika, and emerging
infectious diseases. J Glob Infect Dis. 2017;9:151–6.
2. http://legislatie.just.ro/Public/DetaliiDocumentAfis/223831
3. http://www.cnas.ro/national-page/hg-nr-252.html
4. http://www.cnas.ro/cjastm/media/postFiles/Ordin%20555_2020.pdf
5. http://statistici.insse.ro:8077/tempo-online/
6. https://ec.europa.eu/eurostat/web/regions-and-cities/overview
7. https://www.cnscbt.ro/index.php/analiza-cazuri-confirmate-covid19/1539-
analiza-cazuri-confirmate-261-pana-la-18-03-2020/file
8. https://e-psihiatrie.ro/raspunsurile-cnas-si-cnsmla-cu-privire-la-harta-
serviciilor-de-psihiatrie-din-romania/
31
 research

Lorena Mihaela
Muntean1,2,
Aurel Nireștean1,2,
Emese Lukacs1,2
1. “George Emil Palade”
University of Medicine,
Pharmacy, Science and
Technology of Târgu-Mureș,
Romania
2. Psychiatric Clinic II,
Mureș County Clinical Hospital,
Târgu-Mureș, Romania
Corresponding author:
Lorena Mihaela Muntean
E-mail: lorenaa_a@yahoo.com
Individual personological
features in the professional
choice of medical students
and resident doctors
Abstract
The medical specialty contributes to the professional
training process through the development of personal skills,
through the permanent accumulation of knowledge, but
also through the acquisition of new skills, things that are
dependent on each individual personality. Choosing an
inappropriate specialty can lead to a low level of fulfillment
and resolution of the specific requirements of the profession,
failures, frustrations, lack of satisfaction and self-
affirmation through the profession, overwork, aspects that
sometimes even lead to loss of control. Their presence for a
longer period can trigger the burnout syndrome. That is why
it is very important that the medical specialty be chosen
in accordance with the personality, individual abilities,
interests, values, but also with personal expectations.
Quality of life pursues several aspects, such as physical and
mental health, self-esteem, interpersonal relationships
and environmental conditions. The right medical specialty
will improve the quality of the medical act through the
ability to fulfill the obligations at work, but at the same
time it also contributes to increasing the quality of life by
reducing stress at work. This approach can be integrated
in the future in educational programs in order to guide
medical graduates in choosing the right medical specialty.
Keywords: medical specialty, quality of life, personality
traits, motivation, dimensional perspective
Rezumat
Specialitatea medicală contribuie la procesul de formare
profesională, prin dezvoltarea competențelor personale, prin
acumularea permanentă de cunoștințe, dar și prin dobândirea
de noi abilități, lucruri care sunt dependente de personalitatea
fiecăruia. Alegerea unei specialități nepotrivite poate duce la
un nivel scăzut de îndeplinire și rezolvare a cerințelor specifice
profesiei, la eșecuri, frustrări, lipsa satisfacțiilor și afirmării
de sine prin profesie sau suprasolicitare, aspecte care uneori
duc chiar la pierderea controlului. Prezența acestora mai
mult timp poate declanșa sindromul de burnout. De aceea,
este foarte important ca specialitatea medicală să fie aleasă
în concordanță cu personalitatea, abilitățile individuale,
interesele, valorile, dar și cu așteptările personale. Calitatea
vieții urmărește mai multe aspecte, precum sănătatea fizică și
psihică, stima de sine, relațiile interpersonale, cât și condițiile
de mediu. Specialitatea medicală potrivită va îmbunătăți
calitatea actului medical prin capacitatea persoanei de a-și
îndeplini obligațiile la locul de muncă, dar în același timp
contribuie și la creșterea calității vieții, prin reducerea stresului
la locul de muncă. Acest demers poate fi integrat în viitor în
programe educaționale, în vederea ghidării absolvenților
mediciniști în alegerea specialității medicale potrivite.
Cuvinte-cheie: specialitate medicală, calitatea
vieții, trăsături de personalitate, motivație, perspectivă
dimensională

Recieved:
30.03.2021 Trăsături personologice individuale în opțiunea profesională a studenților
Accepted:
12.04.2021 mediciniști și a medicilor rezidenți
Suggested citation for this article: Muntean LM, Nireștean A, Emese L. Individual personological features in the professional choice of medical students and resident
doctors. Psihiatru.ro. 2021;64(1):32-34

Medical education involves investments of material
resources, time and energy, whose beneficiary will be
in the end the patient (1).
The medical specialty contributes to the profession
training process through the development of personal
skills and accumulation of knowledge, things that are
dependent on each individual’s personality. In this way,
the personality is in close connection with profession(2).
Personality is considered to be the most important
factor in the choice of medical professional. The profes-
sion satisfies the personality characteristics in terms
of aspirations and level of achievement (3).
Doctors are often viewed through the chosen spe-
cialty (4). The choice of medical profession is influenced
by personal motivation, personal interests and values,
aspects related to personal subjectivity. Academic
achievements, the possibilities offered by the specialty
as a social and financial status, the opportunities
related to research, but also the possibility to prac-
tice the specialty in the private or public system are
factors related to the objective conditions (5).
In many cases, there are discrepancies and mis-
matches between the personal style and the charac-
teristics of the medical field chosen(6).

32 Anul XVI • Nr. 64 (1/2021)


An improvement in the quality of the medical act
can be obtained by studying the personality of doc-
tors. The right specialty will help reduce stress at work
that can reach high levels, the medical career being
one of the most stressful professions (3).
The quality of life of both the student and the doctor
includes several aspects, such as physical and mental
health, interpersonal relationships at work and in the
family, but also the conditions in which the student
or doctor lives and works(7). Throughout their careers,
doctors are attentive to the quality of life of patients,
thus neglecting their personal life, which over time can
lead to a decrease in the quality of life. The existing
studies currently suggest that medical students have
a lower quality of life than people of the same age in
the general population. This is due to the unbalanced
lifestyle, academic failures that impact the student’s
mental state, factors related to the environment in
which they operate, interpersonal relationships that
due to the busy schedule may be lacking, but also low
self-esteem(8). That is why it can become difficult to
find a balance between academic requirements and
daily activities.
As a student or doctor, motivation is an extremely
important aspect in the medical career. Motivation is
defined as the process by which a person is mobilized
to achieve goals. Motivation for profession is made
up of several factors that determine the engagement
in a behavior. The most important internal factor is
represented by personality. The external factors are
represented by environmental factors. Motivation is
a faceted construct that includes: confidence in one’s
own abilities, reasons for engaging in the activity, but
also the reactions that the activity provokes. This
can be seen as a process of choosing the goal and the
effort required to achieve it (9).
Motivational involvement is the qualitative and
adaptive aspect of motivation and refers to a person’s
ability and willingness to set certain goals and try
to achieve them. In other words, motivational in-
volvement can be represented by activating, but also
motivational targeting to achieve the proposed goal.
Through motivational involvement, one can identify
job satisfaction from which we can extrapolate indi-
vidual and professional productivity (9).
Motivational persistence provides the quantitative
component of motivation, representing a person’s
ability to persevere and make an effort to achieve
the proposed goals. It follows several elements: the
effort that represents the energy exerted by a person
to achieve the goals; self-confidence; the perseverance
with which the person directs his effort to achieve
the goals; the purpose for which the person engages
in the activity; organizing the dosing of the effort to
achieve the objectives; focusing on the essentials, on
the activities necessary to achieve the objectives; the
obstacle that can intervene and the ability to overcome
it, but also the ambition to achieve more than others
and to be in competition(9).
Anul XVI • Nr. 64 (1/2021)
psihiatru
In Romania, the duration of the faculty of medicine is
six years, training that ends with the bachelor’s exam. In
order to be able to complete the residency training, the
graduates must take the residency exam. In this regard,
the choice of medical specialty can be an elaborate,
conjunctural or imposed option and is conditioned by
several factors. The first factor mentioned is individual
self-knowledge, in the sense of matching the character-
istics of professional activity, the dominance of person-
ality and the intellectual and physical abilities of the
doctor. The second factor that can condition the choice
of specialty is represented by the work places that are
provided by the Ministry of Health. The third factor is
represented by the grade acquired by the future doctor at
the National Residency Contest. The family model plays
an important role, as there are professions with family
transmission. Another aspect is related to the social and
financial status that each specialty can offer; there are
specialties with an incre ased danger that can make a
specialty more attractive from a financial point of view.
The international literature has shown that surgeons
are confident in their own strengths with increased
extroversion, supported by Mehmood et al. (2013)(11).
Psychiatrists have a lower conscientiousness than the
rest of doctors form the other specialties, as demon-
strated by Bexelius et al. (2016)(6). Mullola et al. (2018)
argue that physicians in paraclinical specialties have
low extroversion(1). Internists have increased consci-
entiousness, as highlighted by Mullola et al. (2018)(1).
The sample of the study consists of a number of 129
resident doctors from different medical specialties,
whose personality was evaluated from a dimensional
point of view, after the Big Five model, with the help
of the DECAS personality inventory scale.
Given the importance of personality in different
medical specialties, our first study (10) was conducted
on 129 doctors as subjects, from different specialties:
18 resident doctors in surgery (13.96%), 34 resident
doctors in psychiatry (26.36%), 42 resident doctors
in internal medicine (32.56%), 11 resident doctors in
paraclinical specialties (8.51%), and 24 resident doc-
tors in other specialties (18.61%). 
The personality profile of the resident doctors in
surgery is associated with increased levels of extraver-
sion (p<0.0049) and agreability (p<0.0440). People with
high extroversion are pragmatic individuals, who take
easy risks, are talkative, enthusiastic, optimistic and
self-confident. They prefer action and rapid take-up
of the initiative (10).
Resident doctors in psychiatry are characterized
as casual people, who manifest easily and have a
nonconformist spirit.
Those who have opted for this specialty have high
values of agreeableness compared to doctors in other
specialties (p<0.0382). Doctors dominated by this di-
mension are altruistic people, less pretentious, with
high common sense, friendly and with a high degree
of empathy, they trust those around them. Increased
emotional stability characterizes psychiatrists as
33
research
strong, persevering, rational in thinking, with well-
developed coping mechanisms to deal with extreme
situations (10). On the other hand, the study highlights
lower values of conscientiousness in psychiatric resi-
dents compared to other specialties (p<0.0151).
Internal medicine residents have increased agreea-
bleness and conscientiousness (p<0.0478). The in-
creased agreeableness characterizes doctors as al-
truistic, friendly, empathetic people, trusting those
around them, being oriented towards the needs of
those around them. Increased conscientiousness
indicates a high level of control, perseverance and
meticulousness, the activities undertaken being well
organized and structured(10).
Resident doctors in paraclinical specialties are pre-
dominantly introverted, a dimension accentuated by
the reduced contact with the patient. They have a low
extraversion dimension of personality (p<0.0284), avoid-
ing taking the initiative due to the fact that they deplete
them energetically, preferring solitary activities(10).
Low emotional stability in doctors of other medical
specialties can be explained by the fact that there is a
structural anxiety that in a first phase can be adaptive,
but if stressors intervene, it can manifest clinically (10).
It is proven that the conscientiousness is the fac-
tor that frames the doctor in the professional role.
High conscientiousness indicates an increased level
of control, perseverance and meticulousness (12) . It
can be considered a marker of efficiency, but also of
success in the medical profession.
1. Mullola S, Hakulinen C, Presseau J, et al. Personality traits and career choices
References
among physicians in Finland: employment sector, clinical patient contact,
specialty and change of specialty. BMC Med Educ. 2018;18(1):52.
2. Fang JT, Lii SC. Relationship between personality traits and choosing a medical
specialty. J Formos Med Assoc. 2015;114(11):1116-1121.
3. Nireștean A, Ardelean M. Personalitate și profesie. Târgu-Mureș. Univeristy Press.
2001.
4. Chang YC, Tseng HM, Xiao X, Ngerng RYL, Wu CL, Chaou CH. Examining the
association of career stage and medical specialty with personality preferences –
a cross-sectional survey of junior doctors and attending physicians from various
specialties. BMC Med Educ. 2019;19(1):363.
5. Kuriata A, Borys E, Misiolek U, et al. Choice of medical specialty and personality
traits measured with the EPQ-R(S) in medical students and specialist doctors.
Archives of psychiatry and psychotherapy. 2019;21(2):56-70.
6. Bexelius TS, Olsson C, Järnbert-Pettersson H, Parmskog M, Ponzer S, Dahlin
M. Association between personality traits and future choice of specialisation
among Swedish doctors: a cross-sectional study. Postgrad Med J. 2016
34
Choosing an inappropriate specialty can lead to a
low level of fulfillment and resolution of the specific
requirements of the profession, to failures, frustra-
tions, lack of satisfaction and self-assertion through
the profession, overwork, and loss of control. Their
persistence for a long period can trigger the burnout
syndrome.
In the medical profession, the highest degree of
satisfaction remains the one offered by the specialty,
the quality of the doctor’s life and the life satisfactions
that are based on the quality of the involvement and
the results of the medical act.
Extensive research in this field is absolutely neces-
sary due to the large number of resident doctors who
change their chosen specialty motivated by the fact
that they realize that they are incompatible with
working conditions, with the time spent in hospital,
but also with the expectations that are not in line
with reality, therefore the choice of medical specialty
is extremely important to the future.
The potential impact of the research results un-
derlines the fact that self-knowledge in the sense of
personality dimensions allows the recognition of per-
sonological factors that can facilitate an appropriate
choice according to their skills in vocational training.
The results of such a study can be integrated into
educational programs in order to support the decision-
making process in choosing the medical specialty and
in increasing the efficiency of the medical act and the
quality of life in the medical world. n
Aug;92(1090):441-6.
7. Maron BA, Fein S, Maron BJ, Hillel AT, El Baghdadi MM, Rodenhauser P. Ability of
prospective assessment of personality profiles to predict the practice specialty
of medical students. Proc (Bayl Univ Med Cent). 2007;20(1):22–26.
8. Pagnin D, de Queiroz V. Comparison of quality of life between medical
students and young general populations. Educ Health (Abingdon). 2015 Sep-
Dec;28(3):209-12.
9. Constantin T. Determinanți ai motivației în muncă de la teorie la analiza realității
organizațională. Editura Universității „Alexandru Ioan Cuza” Iași. 2009.
10. Muntean LM, Nireștean AP, Lukacs E. Dimensional personological predisposition
in the medical professional choice. Romanian Journal of Psychiatry. 2019
Sep;XXI(3):150-153.
11. Mehmood SI, Khan MA, Walsh KM, Borleffs JCC. Personality types and specialist
choices in medical students. Medical Teacher. 2013;35(1):63–8.
12. Israel S, Moffitt TE. Assessing conscientious personality in primary care: an op­
portunity for prevention and health promotion. Dev Psychol. 2014;50(5):1475-1477.
Reclamă Psih 64(1)0105
Anul XVI • Nr. 64 (1/2021)
 X I V -A
EDI Ț IA A 2 0 21
I E
14 - 17 IUL
T V I R T U A L
E V ENIMEN
Organizator: Parteneri științifici: Sub egida:

Asociatia Româna
de Psihiatrie si Psihoterapie

Asociația Română de Colegiul Psihologilor Universitatea de Medicină și Farmacie Academia de Științe Medicale
Psihiatrie și Psihoterapie din România „Iuliu Hațieganu”, Cluj-Napoca din România

CONFERINŢA NAŢIONALĂ
DE PSIHIATRIE
cu participare internaţională

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book review
Oxford Handbook
of Psychiatry
Ilinca Untu, Roxana Chiriță
“Grigore T. Popa” University of Medicine and Pharmacy, Iași; Socola Institute of Psychiatry, Iași, Romania
The Oxford Handbook of Psychiatry embodies all
major psychiatric disorders, focusing on psychiatric
subspecialties and thus providing an overview, cre-
ated from a practical and comprehensive perspective
of addressing mental disorders, their psychopathol-
ogy, evidence-based practice, the problems they raise
regarding therapy and psychotherapy, or when it
comes to cross-cultural psychiatry. This handbook
was updated in December 2015, in order to ref lect
the new trends in the field.
The book was published in February 2013 in edited
format and in March 2013 appeared in online format
at the Oxford University Press, UK. In 2014, it was
awarded the BMA Book Awards, having a favorable
reception and numerous reviews and comments that
support its usefulness and importance in the field.
The authors of the book are David Semple, psychia-
trist consultant at the Hairmyres University Hospital
and honorary member of the Psychiatry Division of
the University of Edinburgh, UK, and Roger Smith,
psychiatrist consultant in the Department of Medical
Psychology at the Royal Infirmary of Edinburgh and
Honorary Clinical Senior Lecturer at the University
of Edinburgh.
The acknowledgement section cites all the co-au-
thors who contributed to the creation of the chapters
of this handbook. This book has reached its fourth
edition, marking a new beginning, including all the
updates provided by the most current version of the
classification launched by the American Psychiatric
Association, DSM-5. The entire text of the previous
edition has been revised, in order to reorient the
content to mark the evolution of ideas that directly
and indirectly inf luence psychiatric thinking. This
directive includes notions of global mental health
and gender issues. At the same time, taking into
account the newly found knowledge regarding the
biological mechanisms underlying the mental disor-
ders, the handbook is provided with a new section of
neuropsychiatry, with a new conceptual definition of
what neuropsychiatry really represents.
The authors made this update to the Oxford Hand-
book of Psychiatry to encourage scientific thinking
with holistic tendencies, taking into account the wide
range of areas that influence the current practice of
psychiatrists, such as philosophy, ethics, sociology
and forensic issues.
36
The handbook has 1147 pages and is divided into 26
chapters, covering all areas of interest in contempo-
rary psychiatry, starting from a chapter aimed at the
conceptual framework of psychiatry with a review of
scientific guidelines, the role of the psychiatrist, myths
related to the psychiatric disease, stigma and the notion
of mental disorder, continuing with a section dedicated
to psychiatric evaluation and one that essentially refers
to the fundamental basics of psychiatric semiology, then
moves on to a chapter of neuropsychiatry to then be pre-
sented, in a clear and systematic way, the main mental
disorders (schizophrenia and other psychotic disorders,
depressive disorders, bipolar disorders, anxiety spectrum
disorders, eating and impulse control disorders, sleep
disorders, reproductive psychiatry, personality disor-
ders, gerontopsychiatry, disorders related to psychoac-
tive substance use, mental disorders of the child and
adolescent), followed by a chapter dedicated to forensic
psychiatry, one related to intellectual disability, another
on liaison psychiatry, a section on various aspects and
notions of psychotherapy, and sections on legal issues in
psychiatric medical practice, cross-cultural psychiatry,
therapeutic approaches, major psychiatric emergencies,
useful resources and an index reported to ICD-10 and
DSM-5. In addition, right at the beginning of the book,
we find a section of symbols and abbreviations.
The first chapter, Thinking about psychiatry, is prefigured
as an introductory section, as an exhaustive description
of the place of mental illness, psychiatrist and psychia-
try in the medical world, with subchapters on disease
definition, psychiatric diagnosis, perception of psychiatry,
psychomitology, stigma, antipsychiatry and a very short
but conclusive section on the history of psychiatry. In
addition, the first chapter addresses some issues related
to the current practice of the psychiatrist and the nature
and effects of his work: Why do psychiatrists look at the
brain ?, Can psychotherapy change the brain ?, The power
of placebo, Treating patients against their will.
The second chapter, entitled Psychiatric assessment,
manages to create a clear, detailed and concise picture
of what the psychiatric interview means, starting from
describing the interview preparation, how to manage
the dialogue with a psychiatric patient, some tricks re-
garding obtaining anamnestic data, with fundamental
details from the patient’s personal and family history, up
to the examination on mental functions of the patient’s
mental state. In addition, the chapter is provided with
Anul XVI • Nr. 64 (1/2021)

a section on summarizing the case, including the most
important elements of the patient’s personal and medical
history, the psychiatric examination itself, suicide risk
assessment and disease insight, followed by differential
diagnostic algorithms, the approach of the case according
to predisposing, precipitating and perpetuating factors
and the management plan, taking into account all the
information previously described.
Anul XVI • Nr. 64 (1/2021)
psihiatru
The third chapter, Symptoms of psychiatric illness,
contains a very brief overview of psychiatric symptoms,
followed by a section entitled Dictionary of psychiatric
symptoms, which explains clearly and synthetically
the main semiological notions of psychiatry, but also
a series of terms that refer to adverse effects of psycho-
tropic medication, thus foreshadowing an instrument
of work in itself through the clarity and eloquence of
the description and explanation of these notions.
The fourth chapter, Neuropsychiatry, focuses on
the role of neurological examination, on the organic
implications of neurological factors in the patho-
genesis of mental disorders, on neurodevelopmental
features, neuropsychiatric peculiarities in epilepsy,
nonvascular dementia, prion infection, HIV infection,
autoimmune diseases and psychiatric complications
following strokes.
Chapters five consists of twelve major psychiatric
diagnoses, starting with Schizophrenia and related
psychoses, Depressive illness, Bipolar illness and up to
Anxiety and stress-related disorders, Eating and impulse-
control disorders, Sleep-wake disorders, Reproductive
psychiatry, sexual health and gender related issues and
Personality disorders. They are organized and synthetic,
containing fundamental information for the recognition,
diagnosis and therapeutic approach of each mental dis-
order, with various information related to the research
history in a certain area of psychiatric pathology, but
also historical landmarks of the disorder, epidemiol-
ogy and, last but not least, pathogenesis. The positive
diagnosis relates to both ICD 10 and DSM-5 criteria. In
addition, the chapters are provided with descriptions of
the clinical features of each mental disorder, described
in detail and related to the practical intervention of the
specialist. Psychopharmacological therapy is presented
in accordance with the international guidelines, but
does not omit the off-label recommendations, offering
therapeutic switch strategies, as well as options for
initiating psychotropic therapy.
The thirteenth chapter, entitled Old age psychiatry,
provides a synthetic picture of the psychopathology of
the elderly, including the issue of overspecialization
in old age psychiatry. In addition, beyond the clinical
aspects and the psychopharmacological approach, we
find a related section of various legal issues intercon-
nected with this area of expertise.
The fourteenth chapter, Substance misuse, focuses
on information on the clinical aspects and therapy
of mental disorders resulting from the abusive use of
psychoactive substances, starting with a definition of
the addiction syndrome. Thus, the substances to which
the chapter refers are alcohol, tobacco and illicit drugs
such as opioids, stimulants, hallucinogens, volatile
substances etc., introducing the notion of legal highs.
The fifteenth chapter, Child and adolescent psychiatry,
includes clinical-therapeutic notions related to mental
disorders characteristic of childhood and adolescence,
with particularization of the approach to psychophar-
macological therapy, but also family psychotherapy.
37
book review
Forensic psychiatry, the sixteenth chapter, details a
series of aspects related to forensic psychiatry, with
legislative references and methods for assessing the
risk of aggression, detailing the correlation between
crime and mental disorder and describing the most
secure medical units.
The seventeenth chapter refers to Intellectual dis-
ability, providing a holistic picture on this subject,
detailing the etiology, highlighting the clinical cir-
cumstances most commonly associated with intel-
lectual disability, and highlighting the benchmarks of
therapeutic management and management of family
problems or even medico-legal implications.
Liaison psychiatry, the eighteenth chapter, aims
at the clinical-therapeutic approach of concourrent
or comorbid psychiatric syndromes with somatic
disorders.
The next chapter, the nineteenth, Psychotherapy,
offers both a historical perspective on psychotherapy
and a series of indications and actual psychothera-
peutic orientations and techniques, defining the
fundamental role, both therapeutic and especially
focused on social reintegration and increasing the
patient’s quality of life.
The twentieth chapter, Legal issues, refers to legisla-
tive particularities aimed at mental health, specific
to the UK.
Chapter twenty-one is dedicated to Transcultural
Psychiatry, and the next one, twenty-second, deals
with Therapeutic issues, focused on the idea of thera-
peutic adherence, the side effects of psychotropic
medication and a series of particular clinical condi-
tions that impose adjustments or restrictions on the
administration of psychotropic drugs.
38
The twenty-third chapter, Difficult and urgent situ-
ations, essentially refers to the management of major
psychiatric emergencies, with an original final section,
dealing with a subject often overlooked, the mental
health of doctors.
Chapter 24 includes useful resources, addresses,
e-mails, contact phone numbers, useful to patients
suffering from various mental disorders.
The 25th chapter includes an ICD-10/DSM-5 index,
useful in systematizing and providing an operational
meaning to the diagnostic criteria, followed by an
alphabetical index with corresponding reference of
the pages where the terms can be found.
Oxford Handbook of Psychiatry is an extremely focused
and clear clinical-therapeutic guidance tool, which
has the schematic aspect of a real guide, clarifying the
issue of positive and differential diagnosis, as well as
classical and off-label therapeutic approaches, with
association strategies, switch and increasing doses of
psychotropic medication. However, it does not neglect
the forensic and social aspects, inextricably linked to
psychiatric practice, including a series of operative no-
tions of psychiatry. The logical and schematic aspect
of the book, the succession of the chapters, the ample
thematic treated and the practical illustration of some
situations make this book an indispensable tool for
young psychiatrists and an absolutely necessary instru-
ment for the experienced practitioners. n
Reclamă Psih 64(1)0106
Anul XVI • Nr. 64 (1/2021)
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psyhiatry&art&culture
Genius and suicide (part II)
Doina Cozman
Prof. univ. dr. at "Iuliu Hațieganu" University of Medicine and Pharmacy , Cluj-Napoca, Romania
Death – or, more precisely, living one’s own death
– is a feeling integrated into the depth of any human
being. That such an intimate feeling is kept in silence
for most of the time is no wonder, given that so many
fundamental psychological phenomena (such as “the
lived body”, or the corporal cenesthetic sense), in their
their turn, remain hidden and silent, until an event or
the pathology bring them to the forefront of existence.
When someone begins to think his own death, his con-
sciousness is doubled in two spaces, one of reality and one
of non-reality, but also of non-being. That second space,
the person tries to transform into a conceptual, virtual
space, in which the concept of non-being is integrated
with that of a living being, in his consciousness, because
the consciousness is not synonymous with the feeling
of life. Taking into account some possible end is not in
any way close to reverie, of imagining the state of non-
being. For the living subject, death is something that is
imposed from outside, it is an exogenous phenomenon,
many rebelling against it, this rebellion being triggered
by the feeling of injustice.
The majority of self-murderers pertain to the cat-
egory of despair, indifferent of the cause or causes
that have generated the despair. The despair is a psy-
chiatric state that imposes itself to the subject who
lives it, and its load is unbearable. The despair cannot
be approached progressively; the man falls in despair
unexpectedly as sitting on the brink of a precipice.
But what sense could get the act, the action, the
summing of behaviors that ultimately transform the
being in the non-being?
If death is absurd for the living ones, the self-mur-
derer seeks to give it a sense, an ultimate sense. Most
of the times, this is represented as an act of aggres-
sion, self-directed, maybe sometimes from the lack of
possibility to direct it to somebody else. In that way,
the autoaggression is in continuity with the “global”
personality, the self‑destructive behavior, not always
explained by immediate causes, but not outside the
circumstances (1).
Let us say together with Sartre: “The death is absurd
as it does not pertain to any project. What would
be life if it would not have, in a potential future, an
expectance?... In a word, the consciousness, that for
itself in the measure as it projects into the future,
40
asks again and again an and after. Just because this
for itself is the being that pretends again and again
an and after, there is no place for death in the being
that is for itself ” (translated from French)(2).
The judgement of the suicidal act of a creative per-
son cannot be done only on the basis of criminologi-
cal, sociological, psychological, psychopathological
criteria; at these, we need to add the factor “creative
energy”, “creative vitality” and even that of “creative
consciousness”.
The personality of an artist, of a creator, constitutes
a faithful seismograph of the pulse of his time (3). The
value of the creation does not reside only in their
capacity to give esthetical emotions but, by its reper-
cussions, to play a model role in the society. Creation
is a supreme fulfillment of the personality, the artist
being gifted with peculiar cognitive, intuitive, emo-
tional capacities, transfering himself in the emotions
of the other ones.
In the development of the creative act, the trajec-
tory of the artist’s life may take often a tragic course.
As Tudor Vianu said: “The interest of the artistic life
does not coincide with that of personal conservation.
The artist does not live his life, but consumes it. The
pain felt by an artist may become his creative impulse,
unchained by that signal”.
Many cases of genial artists, writers, painters, musi-
cians are known to have ended their life by self-murder.
Among these are: Van Gogh, Tchaikovsky, Jack London,
Virginia Wolf, Ernest Hemingway, Ernest Kirchner,
Cesare Pavese, and many others. To these, those with
attempted suicide might be added: Gauguin, Schumann,
E.A. Poe, O’Neill, Berlioz. There are also those with
artistic works in which death constitutes a leitmotiv
that crosses as a creepy incantation the whole creation:
Novalis, Lautréamont, Chateaubriand, Camus.
The analysis of some artists’ life who died by suicide
or who attempted a most lethal suicidal attempt imply
the presumption of a real psychopathology.
Analyzing the production of the suicide, we note
that all the aforementioned artists went through a
phase of incubation of the suicidal motivation, a time
in which the unfavorable conjecture and the decrease
of the creative power crystalized on the mental plane
in the idea of the necessity of the death.
Anul XVI • Nr. 64 (1/2021)

The case of Gauguin
The life of Paul Gauguin constitutes a rich study
material for psychiatrists. His personality, marked by
unwontedness and nonconformism, triggered wonder
and disapproval in his contemporaries (5).
As it happens many times in the case of art crea-
tors, the man stood many times hidden behind his
official biography. Gauguin was an artist with a life
full of exotism and mystery, that contributed to the
creation of “the legend of Gauguin”, creating at first
the anecdote about the man and only next, the un-
derstanding for the artist. The separation from the
social traditions and ethical-moral bourgeois norms
was many times thought as the sign of an alienated
personality. Leaving his large family and a wealthy
existence for a doubtful career of a painter, his ad-
venturous travels in the Southern Seas and finding
the paradise in the Oceania Islands received new
interpretations in the actual vision. Of course, there
were some psychopathological elements in the be-
havior and the thinking of the artist: extreme affec-
tive oscillations, megalomania, demonstrativeness,
egocentrism, hedonist tendencies, poly-toxicophylia
(alcohol, absinthe, opium). To that exalted nature, in
balance between visionary enthusiasm and organic
despair, the art acted as a regenerator medium. The
consideration of all the factors that determined the
structuring of this personality (childhood, family tra-
dition, the educational process) brings new meanings
in the explanation of “the myth of Gauguin”.
Anul XVI • Nr. 64 (1/2021)
psihiatru
Figure 1. Paul Gaugin –
"Portrait of the Artist with
the Yellow Christ"
PHOTO: WIKIMEDIA COMMONS
He spent his childhood in Lima, where the Gauguin
family was in exile, living in the house of his uncle, a
Peruvian statesman. He lived a wealthy life in an exotic
and luxurious atmosphere. Returned to France, at the
age of 15 years old, he embarked on different merchant
ships, as a seaman and lately as an officer, and sailed
to South America, Norway, Denmark and the Mediter-
ranean Sea. After the death of his mother, he enters as
a merchant agent in a bank from Paris, proving abil-
ity and know-how in business. For 12 years, he lived a
conformist bourgeois life, proving ability and business
skills. He married, the family life being rich and comfort-
able. Suddenly, he decided to leave the Stock Exchange
to dedicate himself to painting. The family revenues
decreased significantly, so that he separated from his
wife and children whom he left in the care of the rela-
tives. He goes many times in Bretagne, to look for new
inspiration sources, unadulterated by conformism. He
declared himself as a primitive nature and, wishing to
break any link with the civilization, he wandered from
Martinique Island to the Southern Seas, to Tahiti and
Marquises Islands, where, being very ill, he died in 1903.
The biography of the artist has paradoxical dimensions;
the fact of leaving the family, the financial situation, the
honorable social position may be interpreted in a psy-
chopathological but also in a vocational artistic sense(6).
The space covered in his journeys was only a recogni-
tion for himself that the concrete reality does not receive
artistic life only by centralizing the data from utopic
spaces(7). For a utopia of the type “the end of the world”,
41
psyhiatry&art&culture
Tahiti Islands could offer a perfect scenario. Or, maybe
the longing was broader: “The center of my art is in the
brain, I create what is already inside myself”. In fact,
what attracted Gauguin, regarding the way of life of the
natives from Tahiti, was not the total freedom of feeling
and action, but chiefly the landscape of some people where
the fusion with the nature still existed: “You will always
find the nourishing milk in the primitive arts. I doubt
that you will find it in the art of mature civilizations”.
In a crash of his whole being in the precipice of despair,
after hearing the news about the death of his son Clovis,
he attempted suicide himself with arsenic. Being a long
deliberated and premeditated act, he left for the posterity
a painted testament: “Where do we come from? What are
we? Where are we going?”(8) In spite of the preparation
measures for the suicide, by selecting of a powerful poison
and also isolation measures, the painter was found by
the natives and saved by them, through curing methods
used in Polynesia.
However, he only lived shortly after this attempted
suicide. He managed to paint several pictures after that.
His consciousness as artist dictated the last conclusions
of the adventures he passed through: “In any case, I did
my duty and, even if my artwork will not survive, it will
remain the memory of an artist that liberated the art of
painting from academic bizarreness”.
PHOTO: WIKIMEDIA COMMONS
Figure 2. Jack London writing outside, in 1905
42
The case of Jack London
The decay of the creative force made this writer
to take the decision to commit suicide. He writes
in one of his successful novels: “After we concluded
our duties, when the vital force has exhausted, let’s
exist the stage laughing”. Indeed, having chronic
nephritis, when he felt that this moment came, Jack
London committed suicide by concomitant ingestion
of two powerful poisons. The suicide took place on
his domain, being masked in the death certificate by
the diagnosis of uremia.
PHOTO: WIKIMEDIA COMMONS
Figure 3. Robert Schumann in 1839, at the age of 29
(lithograph by Josef Kriehuber)
The case of Robert Schumann
In this composer, the signs of a specific psychiatric
disorder were present (progressive general paralysis),
due to a luetic infection from the youth. During a mel-
ancholic raptus, he ran away from home, summarily
dressed, and drowned himself into the Rhine, but he
was rescued by some fishermen. Next, the depres-
sive episode continuously evolved with a delirious
and hallucinatory symptomatology, with musical
hallucinations sometimes pleasant, sometimes ter-
rific. The disorder debuted clinically in 1852, aggra-
vated progressively, and the depressive states were
accompanied by other alarming symptoms: lack of
coordination of the moments, amnesia, dysarthria,
so that this famous composer finded his end in 1856,
in a dementia state. The attempted suicide, at the
beginning of the illness, coincided with a moment of
lucidity when he realized the severity of his illness.
Anul XVI • Nr. 64 (1/2021)

The case of Kirchner
Ernst Ludwig Kirchner is one of the most representa-
tive from the artistic current of expressionism, a current
appeared in the German space at the beginning of the
20th century as a reaction to academic art constraints.
The expressionists accentuated both the liberation of
the body and also the exploration of the psychiatric with
the gesture and the color. Their art liberated from the
academic canons and it was frequently considered as a
psychopathologic art(8).
Ernst Ludwig Kirchner was born on the 6th of May 1880,
in Aschafensburg, in a family from the high society. In
conformity with the wishes of his father, he begins archi-
tecture studies at the Technical College from Dresden, but
leaves soon for München and next to Nurnberg in order
to study art. Longer visits to museums and art galleries
confirmed the decision to become a perfectionist artist.
Back to Dresden in 1905, he founded the group Die
Brücke, together with his friends Fritz Bleyl, Erich Heckel
and Karl Schmidt-Rotruf, in order to revitalize the German
art, suffocated by the academic tradition(9). The members
of the group wanted to produce art so as to unite the riv-
ers of the past and those of the future. Between 1907 and
1911, he discovered the hedonistic pleasures of plain free
air, very popular in that period, passed on the river of the
Moritzburg Lake, with his friends and their young models.
The activity of the group culminated in 1909 with the big
Exposition Die Brücke at the Richter Gallery in Berlin.
In the same year, he began to paint the night life from
Dresden and Berlin, the cabaret, the dance, the theater, the
prostitutes, being his favorite subjects in that period of life.
In 1910, the group left for Berlin, continuing to expose in
the most important towns of Germany, but also in Moscow
and Prague. The style of Kirchner evolved, specializing
in the representation of the city life, with the cars, speed
and agitated activity of the modern town. In 1912, he met
Ema Schilling, whose he remained devoted to the end.
In 1913, some members of the group Die Brücke
rebelled toward the authoritarianism of Kirchner,
and soon after, the group dissolved.
During his Berlin years, in parallel with the plastic
exploration of the German metropolis, Kirchner falls
prey to regular and excessive alcohol consumption.
After the outbreak of the First World War, in 1915 he was
obliged to fight as “involuntary volunteer” on the battle
front. Not tolerating the soldierly discipline, he fell into
a serious depression. He is dismissed, and send to reha-
bilitation at Taunus, and later at Davos, in Switzerland.
In spite of his increasing dependence of morphine and
alcohol, he achieves to create some of his most impor-
tant works. He immortalizes the terrifying experience
of the war in his painting “Self-portrait as a soldier”. He
paints himself as mutilated, with the right hand being
cut, a symbol of the creative power of the artist. At the
same time, it is a picture with the role of confession, as
in that life period, the depression and suicidal ideation
that will have to put him down later, manifested with a
great power. He continued to work on a farm in the Swiss
Alps, as his health state improved.
Anul XVI • Nr. 64 (1/2021)
psihiatru
PHOTO: WIKIMEDIA COMMONS
Figure 4. Ernst Ludwig Kirchner – "Self-Portrait as a
Soldier" (1915)
In 1921, 50 of his works were exposed to Kronprinzen
Palast in Berlin. The success of the exposition cemented
his role of the leader of the expressionism.
Between 1925 and 1926 he came for the first time in
Germany, after the Swiss exile. His reputation grew
with the printing of the first monograph dedicated to
his work, and due to another appearances in important
magazines. In 1928, he participated to the Venice Biennale,
that confirms his popularity among his compatriots. He
begins to be known in the USA also.
In 1936, the Nazi power qualified the art of Kirchner
as “decadent art” and confiscated all his works from the
German museums, namely 369 paintings, causing him
a great moral suffering. Furthermore, at the exhibition
“Degenerate art” organized by the Nazi in München, 32
of his confiscated works were exposed. Among these,
the painting “Selfportrait as a soldier” with a deliberate
changed title as “Selfportrait with a whore” was exposed.
All the exhibition cast disgrace on the efforts of the artists
to find new forms of expression, with the aim to disavow
the modern art and to qualify it as anti-patriotic. Even
though he was in Switzerland, the disqualification of his
art by the officials of the power produced in the artist a
relapse of the illness, and threw him into a new depres-
sion. During this new depression, he destroyed a great
amount of his works. After he “killed” the last created
pictures, tired and exasperated by the political situation
of Germany, on the 15th of June 1938, he ended his days,
by shooting himself in the heart.
As an irony of destiny, the personal tragedy did not
affect the international recognition of his artistic crea-
tion, his works being exposed in Detroit and New York
with a great success.
43
psyhiatry&art&culture
Common traits of suicides
From the many aspects of the suicide, we retain the
presence of 10 common traits described by Shneidman
in The Definition of Suicide, found in all the categories
of persons that committed the self-murderer act (9).
1. T he common scope of the suicide
is the search for a solution
The suicide is not a random act. It is never a needless
or lacking scope act, but a way of solving a dilemma, a
difficulty, a crisis situation. The suicide has an inherent,
inexorable logic. It is, unfortunately, the unique available
response to the question: “How shall I escape from this
insupportable state?” The fear that narrows the spectrum
of the answers leads to this unique variant.
2. T he common scope of the suicide
is the cessation of the consciousness
Ambivalently, the self-murderer evolves toward
different targets at the same time. First, he wants to
solve his problems, but concomitantly he thrives to
stop the flux of consciousness.
3. T
 he common stimulus in suicide
is the intolerable psychological pain
The normal reaction of every individual is the tendency
to avoid either the physical or the psychological pain. The
enemy of life is the pain, and when it does not come from
soma but from psyche, the psychological pain becomes
a meta-pain, namely the pain to feel the pain.
4. T
 he common stressor in suicide is represented
by frustrated psychological needs
Every self-murderer considers the suicidal behavior as
being very logical, derived from the conditioning imposed
by the subjacent motivation.
5. T he common feeling in suicide is of
helplessness and despair
Unlike at the beginnings of the life, when the stimula-
tion generated by curiosity and discovery is prevalent, the
adult age brings with it the necessity of finding some life
solutions, charged with responsibility. The appearance
of the lack of hope, and of the feeling of helplessness de-
rives from the too heavy burden that this responsibility
charges on the person. The most common formulation of
this feeling would be: “I cannot do nothing – except for
suicide – and I do not find anybody to help me”.
If at the beginning of the century, the psychoanalytical
theories explained suicide by aggressivity, respectively by
retroprojected aggressivity or “crime at 180 degrees”, the
contemporary suicidology considers that other abyssal
emotions explain better the self-murder, such as: shame,
guilt, despair, unaided dependence.
6. T
 he common inner attitude in suicide
is the ambivalence
“We can concomitantly to wish and to reject a thing”,
said Freud. The prototype of the self-murder is that in
44
which the subject cuts his throat and at the same time
cries for help. The person of the self-murderer reunites
in himself at least two tendencies: the self-destruction
and the salvation planning.
7. T
 he common cognition in suicide
is the constriction
The suicide may be understood as a more or less durable
narrowing of the affect and cognition. A “tunnelling”, a
focus of the spectrum of options, that are generally avail-
able in the consciousness of the individual, is produced,
as long as his thinking is not captured by the dichotomic
gap of problem solving in conformity with the slogan
“All or nothing!”.
8. Common action in suicide is the escape
The egression is the intentioned getting out by a
person of a stressful situation, escape that has a differ-
ent signification from flight, this one being a defense
reaction. The suicide is a final egression, a stopping of
the functioning of the real for the person concerned.
9. T he interpersonal act is a communication
of intent
In many cases of death by suicide, “the psychological
autopsy” signalized clear indices of the acts that were to
happen. The ambivalence of the self-murderer determines
him to emit, consciously or not, despair, helplessness,
panic signals and so on. “The suicide drama” is played by
at least two characters, in a dyadic relation. It is sad to
ascertain that the common interpersonal act of suicide
is represented neither by hostility, nor by anger, but by an
unsuccessful attempt to communicate with “the other”.
10. T
 he common aspect of consequence in suicide
is represented by the habitual reaction
pattern of the individual
The suicidal behavior is in the continuity of the person-
ality traits of the self-murderer. The same steadfastness
of the inability to solve the life problems, of the habit to
react to stress in an inadequate way, is found. At an at-
tentive scrutiny, these traits may be deciphered since the
adolescence or youth of the self-murderer. Cesare Pavese(10)
noticed since his first youth, at 20 years old, in his journal:
“No more words. Just the deed… I will cease to write!”. n
References
1. Cosman D. The phenomenology of the suicidal Behavior. Quo vadis. Nr 3, Cluj-
Napoca, 2000, p. 46–48.
2. Sartre JP. Fiinţa şi neantul. Eseu de ontologie fenomenologică. Paralela 45, 2004,
Reclamă Psih 64(1)0107
București.
3. Rouart JM. Cei ce au ales noaptea, Editura de Vest, 1992, Timișoara.
4. Jaspers K. Psychopatologie generale. Librairie Felix Alcan, 1933, Paris.
5. Cosman D. Cultură-personalitate-creație. Studiu de antropologie artistică, în:
Tulburările Personalității – repere clinico-evolutive, sub red. Aurel Nireștean, 2004,
p. 72–78, Ed. Mureș, Tg. Mureș.
6. Walther I. Paul Gauguin (1848–1903). Benedict Taschen Verlag, 1988, Köln.
7. Durand G. Structurile antropologice ale imaginarului, Ed. Univers Enciclopedic,
1998, București.
8. Henze W, Henze I. Kirchner. Grange Books, Rochester, 2005, UK.
9. Shneidman ES. Definition of suicide, New York, 1985, Wiley.
10. Pavese C. Meseria de a trăi. Libris, 2015, București.
Anul XVI • Nr. 64 (1/2021)
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 psychotherapy
General view regarding
the different types of
psychotherapy used for the
treatment of drug addiction
Alexandra Abstract
Boloș1,3, Cristina
Nedelcu2,3, Nicoleta The detailed, accurate national and international situation
regarding drug addiction will always have some weaknesses
Bobutanu2,3, Corina points. The dependence to different drugs, in correlation
Alexinschi3, Marcel with factors related to culture, mentality, self-control, habits
Găină2,3, Ovidiu or low self-esteem, could explain this behavior of searching
Alexinschi2,3 a balance that some people do not find in their private
1. “Grigore T. Popa” University
life. The therapeutic approach is complex and consists of
of Medicine and Pharmacy, Iași, a harmonious combination of pharmacological therapy
Romania with psychotherapy in order to avoid relapses and shape
2. Socola Institute of Psychiatry, the addictive personality. The compliance is essential in
Iași, Romania achieving therapeutic goals; it depends not only on the
3. No Addict Clinic, Iași, Romania patient’s behavior, but also on the therapist's abilities, on
Coresponding author: family, psychosocial and cultural factors. The long-term
Ovidiu Alexinschi prognosis and the evolution of the addicted behavior are
E-mail: alexinschi@yahoo.com individualized especially by the degree of involvement of
the patient and his sociofamilial entourage in obtaining
the best possible therapeutic compliance. Thus, the aim
of this paper is to underline the main important types of
psychotherapies that can be used for drug addiction and
their framing in the general therapeutic management.
Keywords: addiction, psychotherapy, therapeutic
management
Recieved:
20.01.2021 Analiză a principalelor tipuri de psihoterapie folosite în tratamentul
Accepted:
28.02.2021 dependenței de droguri
Suggested citation for this article: Boloș A, Nedelcu C, Bobutanu N, Alexinschi C, Găină M, Alexinschi O. General view regarding the different types of psychotherapy
used for the treatment of drug addiction. Psihiatru.ro. 2021;64(1):46-49
The World Health Organization (WHO) appreciates
that the addiction to alcohol, tobacco and other
substances is constantly increasing and represents a
serious problem of the healthcare system in general
because, beyond the physical and mental dependence,
it determines important consequences at social,
economic or family level. Thus, since 2004, WHOs
report indicates that, worldwide, two billion people
use alcohol and 76.3 million of them already have
complications related to alcohol consumption. People
between the ages of 18 and 24 years old have an
increasing risk of substance abuse. Young men have
higher rates of substance abuse compared to female
46
Rezumat
Situația detaliată, exactă, la nivel național și internațional
referitoare la dependența de droguri va avea întotdeauna
unele puncte nevralgice. Consumul de diferite droguri, în
corelație cu factori ce țin de cultură, mentalitate, autocontrol,
obiceiuri sau stimă de sine scăzută, ar putea explica acest
comportament, de căutare a unui echilibru, pe care unele
persoane nu îl găsesc în intimitatea lor. Abordul terapeutic
este complex și constă dintr-o îmbinare armonioasă a terapiei
farmacologice cu psihoterapia, pentru a putea combate
recidivele și a modela personalitatea adictivă. Complianța
terapeutică este esențială în atingerea obiectivelor, ea
depinzând nu numai de comportamentul pacientului, dar
și de terapeut, familie, precum și de factorii psihosociali
și culturali. Prognosticul îndelungat și evoluția adicțiilor
se individualizează mai ales prin gradul de implicare a
pacientului și a anturajului său sociofamilial în obținerea
unei complianțe terapeutice cât mai bune. În acest sens,
scopul acestei lucrări este de a evidenția principalele tipuri de
psihoterapie ce pot fi utilizate în tratamentul diferitelor adicții
și încadrarea lor în managementul terapeutic general.
Cuvinte-cheie: adicție, psihoterapie, management
terapeutic
adolescents of the same age, but this gender ratio
varies according to the class of substances used (1).
Until recent years, in Romania drugs were little
known among the general population, because it was
only a transit country for most high-risk drugs on
their way to the Western Europe. This has changed
dramatically in the last years, when the consumption of
different types of drugs has increased drastically, and
now this phenomenon is also a source of income or the
goal of an illegal activity, leading to the development
of relatively new health pathologies in our country (2).
The therapeutic management of addictions is
variable, depending on the substance involved, as well
Anul XVI • Nr. 64 (1/2021)

as the specificity of each patient. The way in which we
manage to combine different therapeutic principles,
types of interventions, possibly associated with
specific medication, must focus on the particularity
and individuality of each person. The common goal
is social reintegration, with adequate functionality
in all areas. One of the most important moments of
therapy is probably the initiation of it, preferably as
early as possible. Thus, when a person with addiction
decides to make the first step on this way, he/she must
benefit from all possible services, because otherwise
the fight may be lost before being started.
But which are the therapeutic interventions with
the highest effect on the entire population at risk for
addiction disorders?
What motivates people to change? The correct
response to these issues depends in part on where
they start. How can we trigger motivation to people
to begin thinking about change can be different from
what motivates them to begin preparing to take ac-
tion. As they are prepared, different forces can move
them to take action.  and the solution is only abstinence;
The effectiveness of therapy depends on a number
of factors, such as (3):
n the treatment is applicable and adapted to each type
of patient, according to age, sex, cultural and ethnic
aspects;
n addressing the multiple needs of the individual, and not
only strictly the problem related to the addiction itself;
n addressing also the aspects related to the associated
medical conditions, the possible comorbid mental
disorders, the social, vocational and even the legal
aspects, specific to each case.
Therefore, the therapeutic team must be multidis-
ciplinary, with the aim of combining different types
of therapeutic services, psychotherapy, counseling or
drug therapy, tailored to the needs and specifics of
each individual. One of the important aspects to be
considered in the therapeutic management is the fact
that some people with addictions have, as a comorbidity,
a mental disorder, which in turn requires appropriate
therapy. The patient may also associate addiction with
some infectious diseases that also required appropriate
treatment. Thus, the involvement in addiction-specific
therapy may increase the therapeutic compliance for
many other associated medical conditions.
According to many studies, the duration of the
therapy, in order to achieve a significant reduction or
even stop the use of a drug, is at least three months,
but it can also be for a longer period, depending on
the particularities of each case. Additionally, the ap-
pearance of relapses will determine the resumption
of therapy, possibly its modification and adaptation
according to the new needs of the individual, and
support those interventions that focus on recruiting
and maintaining the individual in therapy, as not to
give up too early.
According to Saunders, the therapeutic management
in case of addictions to different substances highlights
Anul XVI • Nr. 64 (1/2021)
psihiatru
ten main aspects, which must be particularized for
each case, namely (3):
n information and understanding;
n acceptance and involvement;
n initiation of treatment – diagnosis and detoxification;
n pharmacological therapy;
n psychological therapy;
n identification and treatment of comorbidities;
n social and family support;
n support groups;
n post-cure program;
n lifestyle and environmental changes.
The 12-step facilitation therapy (12-step program)
was designed to help the addicted person to participate
in activities that support abstinence and has already
proven effective in alcohol addiction, but it is also used
for other types of addiction. This therapy involves
three basic rules (4):
n acceptance, which will allow to realize that addiction
is a chronic condition, over which there is no control
because it completely changes the lifestyle of a person,
n submission, which represents participation in all
support and assistance structures by specialists and
other people involved in the recovery process;
n active involvement in all activities.
Cognitive-behavioral therapy (CBT) is considered
a short-term therapy which aims to produce an ini-
tial abstinence and subsequent stabilization. But for
many people, only 12-16 sessions are not enough to
stabilize or at least improve the situation, therefore
CBT is only seen as a preparatory therapy for other
long-term therapies.
CBT cannot be used if the patients present psychotic
symptoms or associate another major mental disor-
der, which is not clinically stabilized with adequate
medication, they do not have a stable home, or they
are not stable from a clinical point of view.
CBT can be associated with other types of therapies
such as pharmacological therapy for addiction or for a
mental disorder associated with addiction. Also, it can
be associated with alcoholic group therapies, couple or
family therapy, vocational counseling etc. In this regard,
a therapeutic team is created, which will permanently
maintain the connection concerning the patient’s evo-
lution. In case of CBT, an individual type of therapy is
preferred, which should be adapted to the client’s needs
and will allow a better connection with the long-term
therapist. However, some studies indicate that group
therapy is more effective for people with addiction, thus
putting pressure on other people participating in the
therapeutic group, although the methods used will be
more didactic, appropriate to a group, and will not be
able to be particularized for each person.
Cognitive therapy aims to teach the patient how
to prolong the period without drugs and to avoid
the response from the craving period by engaging in
constructive activities, communicating with other
people in support groups or making a diary.
47
psychotherapy
In case of behavioral therapy, maintaining absti-
nence can be achieved by the following aspects:
n addressing the motivational aspects for change of
the client;
n developing specific skills to withstand substance use,
creating incentives to maintain change;
n facilitating interpersonal relationships;
n improving problem-solving skills;
n replacing substance-specific activities with other
appropriate reward-type activities;
n individual, group or other forms of support for people
with addiction.
Considering the chronicity and complication of
alcohol addiction, we have to assess the motivation
to care, the ability to control himself/herself, and
the opportunity of a biological treatment, such as an
aversion treatment with disulfiram.
We should try to introduce the Golden Rules for
exposure treatment and the role of co-therapist (a
friend or wife/husband). In many cases, alcohol is
reported to be used as a form of self-medication.
When the patient will be able to control alcohol
ingestion, we may go ahead with the program of the
exposure diary (4).
The community approach to reinforcement, as de-
fined by Meyers and Smith in 1995, is “a broad-spectrum
behavioral treatment for substance abuse problems
that uses social, recreational, family and vocational
reinforcements to assist clients in the recovery process.
These factors will contribute to maintaining a drug-
free lifestyle”(5). This therapy includes(6):
n functional analysis of drug use;
n social and recreational counseling;
n councils regarding the professional opportunities
and skills;
n training on drug refusal;
n relaxation techniques, training on behavioral skills;
n advice on relational development.
Motivational improvement therapy (developed by
Miller and Rollnick, 1992) is based on the principles of
motivational psychology and determines an internal
and rapid change, and mobilizes the client’s own change
resources with the help of motivational strategies(7).
Interpersonal therapy (Rounsaville and Carroll,
1993) for addictions is characterized by (8,9):
n adherence to a medical model of mental disorders;
n it focuses on patients’ difficulties regarding interper-
sonal relationships;
n it is concise and the therapist has an exploratory role,
similar to that of supportive therapy.
The resistance highlighted during addiction ther-
apy can be determined by the existence of cognitive
deficits, associated medical conditions, lack of social
support or other environmental stressors. Pregnant
women or prisoners are also particular groups at risk.
Therefore, it is very important to achieve the best pos-
sible case conceptualization, based on a functional
analysis that will determine a f lexible therapy and
adapted to each case.
48
An important issue related to therapy is that of chang-
ing the cultural and socioeconomic context that is
associated with a life without drugs. This therapeutic
challenge is especially encountered in people who have
a long history of illicit drug addiction, which has led to
illicit behavior over time, for example those who sell or
manufacture various drugs. Therefore, in these situa-
tions, the ambivalence regarding the desire for change
increases, especially if it is done slowly and towards a
lifestyle for which they have few skills and few resources,
abandoning a lifestyle to which they felt to belong. Thus,
obtaining new social resources must take into account
the possibilities of each case, offering new opportunities
for employment in various social activities, volunteer-
ing or groups. Also in this context, it can be used the
computer-assisted therapy, which, according to a study
conducted by Carrol and collaborators, showed that the
computer-assisted therapy of CBT, performed twice a
week, determined a period of abstinence longer and
sustained at the six month of assessment compared to
cases in which standard counseling was used(10).
For all those therapists who treat people with vari-
ous addictions, the psychotherapist Newman Cory
said that “there is good news and bad news”. The bad
news is that these people immediately get a positive
but also a negative reinforcement, which will be im-
portant obstacles to therapy, even for those who are
motivated for change. Thus, an effective treatment
must be seen as a difficult and continuous ascent (11).
The areas of therapeutic intervention are repre-
sented, according to Beck, Wright, Newman and
Liese (1993), precisely by those areas of psychological
vulnerability, risk factors for any type of addiction,
and which include (6,11):
n external or internal risk situations for addiction (cer-
tain moods, entourage etc.);
n functional thoughts about the drug and its relationship;
n automatic thoughts that increase the intentionality
of consumption;
n craving, the urgent physiological need to consume
the drug;
n thoughts regarding the permission to consume, which
justifies the use of the drug;
n behavior, sometimes ritually related to drug use;
n psychological manifestations that occur when you do
not use the drug and a vicious circle is made.
“Drug culture” is linked to a subculture of the indi-
vidual, group or family with certain socioeconomic and
psychological standards. Substance abuse is one of the
main causes of morbidity and mortality that could be
prevented and a major contributing factor to many social
problems, such as domestic violence, theft, suicide etc.
The abuse of these substances begins in adolescence,
which is why it requires sustained attention from those
in the healthcare system in general.
An appropriate therapeutic plan must be the basis of
any intervention in the management of drug addiction
and aims to establish a set of realistic specific goals, as
well as appropriate strategies for achieving these goals(12).
Anul XVI • Nr. 64 (1/2021)

The therapeutic plan should be realized only after
a complete evaluation of the patients with addiction,
because this plan must be adapted to their needs
and offer the necessary support in front of the many
difficulties and obstacles that can appear during the
therapeutic process.
Thus, the characteristics of the therapeutic plan
must have the following aspects (13):
n to be detailed;
n to be in accordance with the client’s requirements,
but also be approved by the therapist;
n to be made following the complete evaluation of the
patient, the establishment of the objectives and the
client’s wishes;
n to contain practical, realistic objectives, to contain
strategies for obtaining them;
n to involve the participation of other family members
or friends.
According to Dale and March, this therapeutic plan
must contain(13):
n complete assessment of the patient’s situation;
n assessing patient needs;
n objectives and strategies for obtaining them;
n assessing the need for support and possible limitations
to achieve the objectives;
n modalities to record the progress obtained;
n modalities to evaluate the completion of therapy and
the evolution.
A specific intervention model for alcohol addiction,
according to Mejta and Siegal, is the case manage-
ment, because people with various drug addictions
also have other medical conditions, financial, social or
family problems, and sometimes can associate mental
disorders, which require attention during therapy (14).
The main attributes of case management for drug
addiction are (15):
n identifying customer needs;
n monitoring the evolution during therapy;
n evaluating the types of services that can be provided;
n connecting people with appropriate therapeutic
services.
Thus, patients will benefit from an adequate thera-
peutic assistance, specific to each case, according to
their needs, f lexible, and with cultural specificity.
Case management is efficient when it ensures good
communication between all specialists in the field
involved in therapy, while maintaining the confiden-
tiality of the patients (13).
One of the important aspects in terms of therapeutic
planning and case management is the establishment
of specific objectives. They will be able to guide the
therapy and allow the evaluation of the progress
made (16). Allsop also believes in setting clear goals that
allow therapy to be successful, by counteracting the
effects of learned helplessness, which is a mechanism
specific to people with drug addiction(17).
There are clear objectives, specific to the therapy
of each patient, that will give him a direction, a clear
target, and will also allow the patient to keep a record
Anul XVI • Nr. 64 (1/2021)
psihiatru
of the progress in the therapy (18). The objectives of the
therapy must be adapted and negotiated by each pa-
tient, presented in a specific, clear, achievable terms,
which will focus on the acquisition of skills, and there
are described in positive terms. Also, these objectives
will not be limited only to the addiction itself, but will
also take into account other areas, such as physical
and mental health, social functioning and possible
legal implications of the patients (13).
There is no magic solution for treating addictions.
This is a long process of mobilizing many services. Ad-
diction is a chronic and recurrent disease that requires
repeated treatments until abstinence is achieved.
The treatment will focus on building ego power,
reducing shame and developing social skills. Healing
means a slow work, a long-term therapy, performed
with sincerity and involvement. The therapeutic re-
lationship is formed together with the therapist, who
recognizes and confronts those defense and adapta-
tion mechanisms that no longer work. n
References
1. World Health Organization. Global Status Report on Alcohol 2004. Department
of Mental Health and Substance Abuse. https://www.who.int/substance_abuse/
publications/global_status_report_2004_overview.pdf
2. Prepliceanu D, Voicu V. Abuzul și dependența de substanțe psihoactive. Ed.
InfoMedica. București, 2004.
3. Saunders JB, Conigrave KM, Latt NC, Nutt DJ, Marshall EJ. Addiction Medicine,
Oxford Specialist Handbooks. 2016.
4. Di Fiorino M, Gondek T, Alexinschi O. Exercises of Behavoral Therapy. Ed. La Vela,
Viareggio, 2017.
5. Meyers RJ, Roozen HG, Smith JE. The community reinforcement approach: an
update of the evidence. Alcohol Res Health. 2011;33(4):380-388.
6. https://archives.drugabuse.gov/sites/default/files/cbt.pdf
7. Miller W, Rollnick S. Ten things that motivational interviewing is not. Behavioural
and Cognitive Psychotherapy. 2009;37(2):129-140.
8. Rounsaville BJ, Carroll K. Interpersonal psychotherapy for patients who
abuse drugs. In: Eds. Klerman GL, Weissman MM. 1993. New applications of
interpersonal psychotherapy. American Psychiatric Association.
9. McHugh RK, Hearon BA, Otto MW. Cognitive behavioral therapy for substance
use disorders. Psychiatr Clin North Am. 2010;33(3):511-525.
10. Carroll KM, Ball SA, Martino S, Nich C, Babuscio TA, Nuro KF, et al. Computer-
assisted delivery of cognitive-behavioral therapy for addiction: A randomized
trial of CBT4CBT. Am J of Psych. 2008 Jul;165(7):881-8.
11. Newman CF. Substance abuse. In Whisman MA (Ed.). Adapting cognitive therapy
for depression. 2008. New York: Guilford Press.
12. Davidson R, Velleman R, Mistral W, Howse I. Counselling in substance misuse. A
review of the literature. Alcohol and substance misuse working group. 2005.
13. Dale A, Marsh A. A Guide for Counsellors Working with Alcohol and Other
Drug Users: Core Counselling Skills. Best Practice in Alcohol and Other Drug
Interventions Working Group: School of Psychology. Curtin University of
Technology: Perth, Australia. 2000.
14. Metja C, Bokos P, Mickenberg J, Maslar M, Senay E. Improving substance abuse
treatment access and retention using a case management approach. Journal of
Drug Issues.1997;27(2):329-340.
15. Siegal H. Comprehensive case management for substance abuse treatment.
(Treatment Improvement Protocol (TIP) Series 27.) Substance Abuse and Mental
Health Services Administration: Rockville, MD. 1998.
16. Jarvis T, Tebbutt J, Mattick R. Treatment Approaches for Alcohol and Drug
Dependence; an introductory guide. Chichester: John Wiley and Sons Ltd. 1995.
17. Allsop S. Goal setting. In: Helfgott S (ed). Helping change: The addiction
counsellors training program. Western Australian Alcohol and Drug Authority:
Perth. 1997.
18. Velleman R. Counselling for Alcohol Problems, 2nd Edition. Sage: London. 2001.
49
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