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Redactor ef:
Dan PRELIPCEANU
Redactor-efi
adjunci:
Drago MARINESCU
Aurel NIRETEAN
COLECTIV REDACIONAL
Doina COZMAN
Liana DEHELEAN
Marieta GABO GRECU
Maria LADEA
Cristinel TEFNESCU
Ctlina TUDOSE
Secretari de redacie: Elena CLINESCU
Valentin MATEI
CONSILIU TIINIFIC
Vasile CHIRI (membru de onoare
al Academiei de tiine Medicale,
Iai)
Michael DAVIDSON (Professor, Sackler
School of Medicine Tel Aviv Univ.,
Mount Sinai School of Medicine,
New York)
Virgil ENTESCU (membru al Academiei de
tiine Medicale, Satu Mare)
Ioana MICLUIA (UMF Cluj-Napoca)
erban IONESCU (Universitatea
Paris VIII, Universitatea TroisRivieres, Quebec)
Mircea LZRESCU (membru de onoare al
Academiei de tiine Medicale,
Timisoara)
Juan E. MEZZICH (Professor of Psychiatry
and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
Sinai School of Medicine, New York
University)
Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Department of Psychiatry,
University of Maryland School of
Medicine, Baltimore)
Sorin RIGA (cercettor principal gr.I)
Dan RUJESCU (Head of Psychiatric
Genomics and Neurobiology
and of Division of Molecular and
Clinical Neurobiology, Department
of Psychiatry, Ludwig- MaximiliansUniversity, Munchen)
Eliot SOREL (George Washington
University, Washington DC)
Maria GRIGOROIU-ERBNESCU
(cercettor principal gr.I)
Tudor UDRITOIU (UMF Craiova)
ARPP
REVISTA
ROMN
de
PSIHIATRIE
ASOCIAIA ROMN
DE PSIHIATRIE I PSIHOTERAPIE
Vol XVI
www.romjpsychiat.ro
CNCSIS B+
Nr. 4
December 2014
QUARTERLY
p-ISSN: 1454-7848
e-ISSN: 2068-7176
CUPRINS
109
SPECIAL ARTICLES
Abstract:
Far from being an exception, presence of somatic comorbidities represents the rule in patients with chronic
mental disorders. Co-morbidities can delay diagnosis, can
influence treatment, are related to complications and
affect survival. From these reasons assessment of comorbidities become a necessity in clinical research. One
assessment method is represented by co-morbidity indices.
These instruments used mainly in research offer a global
assessment of associated diseases' severity and are used
especially for mortality prediction. Co-morbidity indices
exclude the primary disease from impact analysis and
focus only on cumulated effect of coexistent diseases. Comorbidity indices are not, however, direct methods of
assessment on health state, for this purpose performance
scales are used. Frailty, a new concept useful in research
and also in clinical practice, aims to explain the different
evolution of patients with comparable co-morbidity load.
Frailty describes a state of global vulnerability to stressors
that determines an unfavorable prognosis. Studied
especially in elderly, frailty is considered a consequence of
multisystemic physiologic decline encountered in these
category of patients. The defining characteristics of frailty
concept are global physiological impairment and
unfavorable answer to stressors. Proposed modalities for
frailty assessment are multiple, reflecting the lack of
consensus on defining frailty. Some assessment
instruments are centered on identification of a clinical
pattern, others use clinical global impression, and others
use a multidimensional approach (including domains like
mobility, physical activity, nutritional state, cognition,
social support, patient's perception on his own health) or
quantifies the number of deficits. Existence of an
association between mental disorders, somatic comorbidities and frailty remains to be established by future
studies, such studies requiring existance of standardized
instruments.
Key words: polipathology, frail, assessment.
1
MD, PhD student, Assistant Professor, Physiology II Neurosciences Department, Faculty of Medicine, Carol Davila University of Medicine and
Pharmacy, Bucharest, Romania. Contact adress: Mihai Viorel Zamfir, Str. Matei Basarab, Nr. 22, Bl. 100, Sc. A, Ap. 3, Bl. 100, Sc. A, Ap. 3, Rm. Vlcea,
Jud. Vlcea. Email: mihai.zamfir@yahoo.com
2
MD, PhD, Assistant Professor, Psychiatry Department, Clinical Psychiatry Hospital Prof. Dr. Alex. Obregia, Faculty of Medicine, Carol Davila
University of Medicine and Pharmacy, Bucharest, Romania
3
MD, PhD, Geriatrics and Gerontology Professor at Faculty of Medicine, Carol Davila University of Medicine and Pharmacy; Head of Geriatrics and
Gerontology Department at Ana Aslan National Institute of Gerontology and Geriatrics, Bucharest, Romania
Received May 16, 2014, Revised June 13, 2014, Accepted July 18, 2014
110
113
114
33. Hall SF. A user's guide to selecting a comorbidity index for clinical
research. J Clin Epidemiol 2006;59(8): 849-55.
34. Dobranici L, Tudose C. The assessment of medical comorbidity in
the elderly patients with dementia / Evaluarea comorbiditii medicale a
vrstnicului cu demen. Rom J Psychiat 2010;2.
35. Linn BS, Linn MW, Lee G. Cumulative Illness Rating Scale. J Am
Geriatr Soc 1968;5: 6226.
36. Kaplan MH, Feinstein AR. The importance of classifying initial comorbidity in evaluating the outcome of diabetes mellitus. J Chron Dis
1974;27: 387404.
37. Charlson ME, Pompei P, Ales KL, Mackenzie CR. A new method of
classifying prognostic comorbidity in longitudinal studies: development
and validation. J Chron Dis 1987;40: 37383.
38. Cleary PD, Greenfield S, Mulley HG et al. Variations in length of stay
and outcomes for six medical and surgical conditions in Massachusets
and California. JAMA 1991;266: 739.
39. Walston J, Hadley EC, Ferrucci L et al. Research agenda for frailty in
older adults: toward a better understanding of physiology and etiology:
summary from the American Geriatrics Society/National Institute on
Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc
2006;54(6): 991-1001.
40. Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state in
a dynamic process. Gerontology 2009;55(5): 539-49.
41. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: evidence
for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56(3): M146-56.
42. Fried LP, Ferrucci L, Darer J et al. Untangling the concepts of
disability, frailty, and comorbidity: implications for improved targeting
and care. J Gerontol A Biol Sci Med Sci 2004;59(3): 255-63.
43. Pel-Littel RE, Schuurmans MJ, Emmelot-Vonk MH, Verhaar HJ.
Frailty: defining and measuring of a concept. J Nutr Health Aging
2009;13(4): 390-4.
44. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of
deficits. J Gerontol A Biol Sci Med Sci 2007;62(7): 722-7.
45. van Kan AG, Rolland Y, Houles M et al. The assessment of frailty in
older adults. Clin Geriatr Med. 2010;26(2): 275-86.
46. van Kan AG, Rolland Y, Bergman H et al. The I.A.N.A Task Force on
frailty assessment of older people in clinical practice. J Nutr Health Agin
2008;12(1): 29-37.
47. Gray SL, Anderson ML, Hubbard RA et al. Frailty and incident
dementia. J Gerontol A Biol Sci Med Sci 2013;68(9): 1083-90.
48. Buchman AS, Boyle PA, Wilson RS et al. Frailty is associated with
incident Alzheimer's disease and cognitive decline in the elderly.
Psychosom Med 2007;69(5): 483-9.
49. Fedarko NS. The biology of aging and frailty. Clin Geriatr Med
2011;27(1): 27-37.
50. Vermeulen J, Neyens J, van Rossum E et al. Predicting ADL
disability in community-dwelling elderly people using physical frailty
indicators: a systematic review. BMC Geriatr 2011;11: 33.
51. Rockwood K, Song X, MacKnight C et al. A global clinical measure
of fitness and frailty in elderly people. CMAJ 2005;173(5): 489-95.
52. Searle SD, Mitnitski A, Gahbauer EA et al. A standard procedure for
creating a frailty index. BMC Geriatr 2008;8: 24.
53. Rockwood K, Andrew M, Mitnitski A. A comparison of two
approaches to measuring frailty in elderly people. J Gerontol A Biol Sci
Med Sci 2007;62(7): 738-43.
54. Jones DM, Song X, Rockwood K. Operationalizing a frailty index
from a standardized comprehensive geriatric assessment. J Am Geriatr
Soc 2004;52(11): 1929-33.
***
REVIEW ARTICLES
DIMENSIONAL PERSONOLOGICAL
PERSPECTIVE ON SUICIDAL BEHAVIOUR
Abstract:
The existence of the human being is delimited by the two
extremes birth and death. The individual's attitude
towards death is always historically and culturally
conditioned. It swings between a serene balance and
respectively a particular fear or sensibility. Nowadays
death is accepted or rejected according to its meanings.
Human beings integrate temperamental, character,
biographic, archetypal components, but also self-reflexive
abilities. These abilities lead to individual self-awareness
and an understanding of life's meanings which favor selfrealization and a subjective well-being. Ideation and
suicidal conducts are the supreme expression of the loss of
existential meanings. Personality traits are among the
personal factors that have major implications on suicidal
behavior. Having a dimensional perspective on these
traits including taking into account the dimensional
facets of personality leads to a more nuanced
understanding of the suicidal phenomenon as well as the
elaboration of early prevention and intervention
strategies.
Key words: suicidal behavior, personality, dimensional
perspective.
Individual existence is delimitated by two
extremes birth and death. The dynamics of the
individual's ages after birth including childhood,
adolescence, adulthood and aging confirms the cyclical
continuity between life's beginning and end. At a certain
stage in its history, psychoanalysis even hypothesized the
existence of two fundamental instincts of life and of
death, respectively of Eros and Thanatos (1). The last
would represent the inherent tendency of organic life
returning to a preceding state, the inorganic state of
existence.
An individual's attitude towards death has
always been historically and culturally conditioned. In an
animated universe according to the concept of animism
fear of death began as a fear of the dead since it was
believed that they could harm the living (2). On the other
hand and in a later period death was considered
happy according to its significances and to the
individual's situation at that moment. That is why the
Vikings were striving to die with the sword in their hand so
that they could enter Wahalla. The manner in which human
beings view death depends on their preservation instinct,
but also on the stage of life they are going through, so that,
for example, at an advanced age death could be looked at
in a detached manner, like a fatality. On the whole, the
individual's attitude towards death swings between a
serene balance cultivated by the ancient Greeks and a
particular fear or sensibility. (3).
The contemporary individual refuses or
accepts death depending on its meanings. Fear of death
represents in the first place fear of the unknown and the
irreversible. Because of social mores death has become an
external show for the individual frightening most of
the time not the intimate act it should have stayed.
Napoleon said priests and physicians made death
painful. On the other hand, not only death but also life is
often accompanied by suffering, and the fear of death
should not be stronger than the fear of life. Moreover,
taking into account the birth trauma, death has been
compared with birth, "sleep and "oblivion being the
dominants (Barbarin quoted by 3).
In general, the way an individual relates to
life's roles and values influences in an obvious manner the
attitude towards death (4). Thus, pragmatic individuals
MD Psychiatry resident, PhD Candidate, Psychiatry Clinic II, UMF Targu Mures
MD, PhD, Professor, Chief of Psychiatry Department, UMF Targu Mures
MD, PhD, Psychiatry Clinic II, UMF Targu Mures
MD, PhD Candidate, Assistant, Psychiatry Clinic II, UMF Targu Mures
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures
Received July 02, 2014, Revised August 29, 2014, Accepted September 26, 2014
115
who are involved in different activities and roles, with prosocial aptitudes, and have a social support network which
is well represented quantitatively and qualitatively, ignore
the idea of death which is overwhelmed and diluted by the
intensity with which they live their life. In their case
memento mori is actually a reference to carpe diem.
Death may also be ignored, and by those for whom life
represents a mean to achieve a value ideal, a goal, who
enjoy a supra-personal respect and appreciation. The
achievement of such a goal brings about great existential
satisfaction and may lead to a reconciliation with death
which can often be manifested by an attitude of
detachment and courage.
It may be considered that living intensely one's
own life in a pragmatic or idealistic way protects the
individual when confronting the eternity of death. On the
other hand, the scarcity of interpersonal relationships and
existential motivations and values, as well as the
dysfunction in various roles of life, disadvantage the
human being before death which appears with all the
negative connotations that may be attributed to it.
It is a known fact that human beings are
products of self-determination and self-becoming.
Biographical experiences, archetypes and self-reflexive
abilities are progressively integrated throughout a
person's life so that in adulthood one becomes self-aware
and aware of one's relationships with others. Dominant
personality traits are both inherited and acquired through
interaction with other people and with the natural world
(5).
Individual self-awareness means implicitly
knowing one's own qualities and flaws, but also being able
to reflect upon the resemblance with people around you, as
well as the challenge of accessing common existential
values. It allows the creation of a feeling of self-realization
and the access to personal happiness. This not only
means the harmony between physical, mental and
spiritual well-being, but a certain subjective well-being
which may result from this harmony and especially from
the understanding of life's meanings.
The approach to life of the mature person must
harmonize the attitude towards himself with the attitude
towards others seen in their own existential context.
Hence, one might learn that life should not be lived as if it
were eternal, and might be able to find and give meaning to
its end.
The contemporary social culture has a
particular dynamics dominated by the phenomena of
technological advancements, urbanization and population
migrations. The abundance and growing diversity of
material goods and services, life models and lifestyles are
often assault the individual's adaptive expectations and
capacities. Old community traditions and customs are
ignored or presented distortedly, as are spiritual and
religious values and ideals (5).
These incessantly altering socio-cultural
conditions have a negative influence on content and
duration of the individual's developmental stages and may
facilitate the development of dominant individualistic
type traits. People who live for themselves prevail
numerically over those dedicated to certain meta-personal
goals.
The individual's attitude towards himself is
dominated by narcissistic and egocentric arguments and
116
***
117
REVIEW ARTICLES
INTRODUCTION
Suicide is a serious health-problem world-wide
and one of the main emergencies in psychiatric practice.
Completed suicide is responsible of 1% of all deaths and is
included, in most regions of the world, in the first ten
causes of death (1). It is even higher in rank in adolescents
and young adults: in ages 15-29 it is the second cause of
death and in ages 30-49 the fifth (1). More than that,
suicide and suicidal behaviour have serious social,
economic and psychological influences impacting both the
persons who commit them, their families and other people
close to them.
In most instances, suicide is a complication of
psychiatric disorders. Approximately 90% of those who
die by suicide have, at the time of death, a psychiatric
diagnosis (1, 2), most of them a diagnosis of mood disorder
(2, 3). Yet, most people who suffer from a mental illness
never even attempt suicide. A study published in 2003
estimated that the suicide rate of affective disorders is
193:100.000, meaning that over 99.000 people suffering
from a mood disorder will never die by suicide (4).
Therefore it is very important to be able to distinguish
those few who are at risk.
Up to date there is no available method that can
accurately distinguish those who will commit suicide from
those who will not.
The importance and the difficulty of the task of
identifying those who are at risk for suicide has lead to an
extensive research on the subject, and to the elaboration of
1
Psychiatry specialist MD, PhD Student, Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, No 10 Berceni Road, Bucharest, Romania. Assistant
Professor, Psychiatry department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; tel: 0724.471.471; e-mail:
am.exergian@gmail.com
Received August 25, 2014, Revised October 06, 2014, Accepted October 31, 2014
118
1.CLINICIAN-RATED INSTRUMENTS
1.1 Scale for Suicide Ideation (SSI)
This is one of the most widely used instruments
for assessing suicide risk, partly due to its extensive
documentation regarding validity and reliability.
It was published in 1979 by Beck et al. (8). It
contains 21 items, of which 5 are screening items (3
regarding the wish to die passive suicidal ideation and 2
regarding the wish to attempt suicide active suicidal
ideation) and 2 are additional items which assess the
incidence and frequency of prior suicide attempts (these
items are not scored). The total score is calculated by
adding the scores of each item, ranging from 0 (none) to 2
(moderate to strong).
Factorial analysis has determined 3 significant
dimensions: active suicidal desire, specific plans
regarding suicide and passive suicidal desire (8).
It has Cronbach coefficient alphas that show
moderately high internal consistency 0.84 (9) to 0.89 (8).
It also has high interrater reliability, with a correlation of
up to 0.98 (8, 9).
The validity of the SSI was established
repeatedly. In the original work, Beck et al found a
significant correlation with the self-harm items from the
Beck Depression Inventory (BDI) (8). Other studies found
significant correlations with previous suicide attempts,
severity of depression and daily self-monitoring of
suicidal ideation (9, 10). It has been proven that the SSI
can discriminate suicide attempters from nonattempters
(11).
It was found that a total score higher than 2
includes the patient in a higher risk category and suggests
a likelihood of suicide that is 7 times higher than for those
with scores of 2 or less (12).
Main advantages of this instrument are:
extensive use in research, well documented validity and
reliability in a variety of populations, and, according to
some authors the fact that it is administered as an interview
(13, 14) . One possible disadvantage is the fact that it has to
be administered by trained clinicians (14).
1.2 Scale for Suicide Ideation Worst (SSI-W)
This scale was published in 1999 by Beck et al.
and contains 19 items scored 0 to 2, according to suicidal
intensity. The SSI-W measures suicidality (behaviors,
thoughts, emotions) at its worst point in the patient's life.
As with SSI, the total score ranges from 0 to 38 (15).
Factorial analysis has found two factors:
preparation and motivation (15).
The Cronbach alpha was found to be 0.88,
representing moderately-high internal consistency (9).
The instrument has high interrater reliability (9). Its
validity was established by correlation with the suicide
item from Hamilton Depression Rating Scale (HAM-D)
and the suicide item of the BDI (9).
It was found that a score higher than 10
delineated a group of patients who were 14 times more
likely to commit suicide, than those with lower scores
(15).
1.3 Suicide Intent Scale (SIS)
This instrument is comprised of 15 items
designed to measure the seriousness of the intent to die
regarding the most recent suicide attempt. It rates
behaviour and communication prior to and during this
suicide attempt (preparation, execution, setting of the
Ana-maria Exergian: Clinical Instruments For The Evaluation Of Suicide Risk An Overview
4 . M E A S U R E S O F S U I C I D E AT T E M P T
LETHALITY
We include in this review some examples of
measures used for suicide attempt lethality because of the
importance of this element has been proven in the
evaluation of suicide risk (43).
Risk-Rescue Rating (44, 45) a clinicianadministered 10 item scale that measures the lethality and
the suicidal intent of a suicide attempt.
Self-Inflicted Injury Severity Form (46) a
clinician-administered 7 item interview designed for use
in emergency departments in order to identify selfinflicted injuries that are life-threatening.
Lethality of Suicide Attempt Rating Scale (47)
a clinician-administered scale designed to measure the
lethality of a suicide attempt. It has 11 items. The total
score ranges from 0 (death is impossible as a result of the
suicidal behaviour) to 10 (death is almost certain
regardless of the intervention of an outside agent; most
people will die quickly after such an attempt). It is
generally considered that a score above 3 signifies that the
attempt is a medically serious one (14).
5.BRIEF SCREENING MEASURES
5.1 Sad Persons
It was published by Patterson et al in 1983 and it
comprises 10 items, several of which are known
demographic risk factors (sex, age and not living with
family or a partner). Other items are: depression, previous
suicide attempts, alcohol abuse, loss of rational thinking,
lack of social support, organised plan of suicide and
somatic illness. Items are scored as 0 absent or 1
present (48).
A modified version of the scale was published in
1988 (MSPS Modified SAD PERSONS score). It also
has 10 items, some different from the original version. The
main difference is due to the assignment of scores 0-2 to
some items (depression or hopelessness, rational thinking
loss and stated future intent determined to repeat or
ambivalent). The importance of this version is that it was
validated for use in screening of patients who require
psychiatric hospitalisation due to suicide risk. Thus a score
of 6 or more suggests the need for hospital admission. The
authors found that this cut-off score resulted in 94%
sensibility and 71% specificity (49).
5.2 Paykel Suicide Items
This is a 5-question interview. The questions
have increasing levels of suicidal intent: 1) Have you
ever felt that life was not worth living?; 2) Have you
ever wished you were dead? for instance, that you could
go to sleep and not wake up?; 3) Have you ever thought
of taking your life, even if you would not really do it?; 4)
Have you ever reached the point where you seriously
considered taking your life or perhaps made plans how
you would go about doing it? and 5) Have you ever
made an attempt to take your life?. The level of the last
question with a positive answer is the score of the scale
(50).
Internal consistency, validity and predictive
value have not been adequately assessed.
5.3 Hamilton Depression Rating Scale (Suicide Item)
It is a clinician-reported item, scored from 0 to 4,
as follows: absent, feels life is not worth living or any
thoughts of possible death to self, wishes he were dead,
121
Ana-maria Exergian: Clinical Instruments For The Evaluation Of Suicide Risk An Overview
43. Leadholm AK, Rothschild AJ, Nielsen J et al. Risk factors for suicide
among 34,671 patients with psychotic and non-psychotic severe
depression. J Affect Disord 2014;156: 119-25.
44. Weissman AD, Worden JW. Risk-Rescue Rating in suicide
assessment. Arch Gen Psychiatry 1972;26: 553-60.
45. Weissman AD, Worden JW. Risk-Rescue Rating in suicide
assessment. In: Beck AT, Resnik HLP, Lettieri DJ (eds). The prediction of
suicide. Philadelphia: Charles Press, 1974.
46. Potter LB, Kresnow M, Powell KE et al. Identification of nearly fatal
suicide attempts: Self-inflicted injury severity form. Suicide Life Threat
Behav 1998;28: 174-86.
47. Smith K, Conroy RW, Ehler BD. Lethality of suicide attempt rating
scale. Suicide Life Threat Behav 1984;14(4): 215-42.
48. Patterson WM, Dohn HH, Bird J, Patterson GA. Evaluation of
suicidal patients: the SAD PERSONS scale. Psychosomatics
1983;24(4): 343-5, 348-9.
49. Hockberger RS, Rothstein RJ. Assessment of suicide potential by
nonpsychiatrists using the SAD PERSONS score. J Emerg Med
1988;6(2): 99-107.
50. Paykel ES, Myers JK, Lindenthal JJ, Tanner J. Suicidal feelings in the
general population: A prevalence study. Br J Psychiatry, 1974;124: 4609.
51. Hamilton M. A rating scale for depression. J Neurol Neurosurg
Psychiatry 1960;23: 56-62.
52. Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. Reasons for
staying alive when you are thinking of killing yourself: The Reasons for
Living Inventory. J Consult Clin Psychol 1983;51(2): 276-86.
53. Strosahl K, Chiles JA, Linehan M. Prediction of suicide intent in
hospitalized parasuicides: Reasons for living, hopelessness, and
depression. Compr Psychiatry 1992;33(6): 366-73.
54. Dean PJ, Range LM, Goggin WC. The escape theory of suicide in
college students: Testing a model that includes perfectionism. Suicide
Life Threat Behav 1996;26: 181-6.
55. Ivanoff A, Jang SJ, Smyth NF, Linehan MM. Fewer reasons for
staying alive when you are thinking of killing yourself: The Brief
Reasons for Living Inventory. J Consult Clin Psychol 1983;51(2): 27686.
***
123
ORIGINAL ARTICLES
Abstract:
Introduction: The dimensional models of personality have
gained ground in the area of trait psychology, fact proven
by the introduction of the alternative DSM-5 model.
Objectives: The aim of the study was to find correlations
between the dimensions of Big five and Big seven.
Method: A group of patients (N= 44) from our Personality
Disorders Register were included in this study. They filled
out two self-administered, paper-and-pencil tests: the
Temperament and Character Inventory(TCI) and the
Disposition (Openness)- ExtraversionC o n s c i e n t i o u s n e s s - A g re e a b i l n e s s - E m o t i o n a l
Stability(DECAS) Inventory.
Results: We have found moderate positive correlation
between Disposition and Self-Transcendence (r=0.51;
p=0.0004) respective Disposition and Persistence (r=56;
p=0.0001) and a strong negative correlation between
Disposition and Harm Avoidance (r=-0.64; p=0.0001).
Extroversion was correlated with Self-Transcendence
(r=0.4; p=0.0044), Novelty Seeking (r=0.43; p=0.0031),
Harm Avoidance (r=-0.72; p=0.0001) and Persistence
(r=0.45; p=0.0021). Conscientiousness is correlated with
Self-Transcendence (r=0.49; p=0.0006), Harm avoidance
(r=-0.5; p=0.0005) and Persistence (r=0.43; p=0.0031).
We have found a moderate positive correlation between
Agreeabilness and Harm Avoidance (r=0.45; p=0.0019).
Conclusions: The comparative comments of the
dimensional evaluation places a premium on the diagnosis
of personality disorders. Self-transcendence has a major
role in understanding personality disorders in any socioculture.
Key words: Personality disorder, alternative DSM-5
model, dimensional models of personality, TCI, DECAS.
processes, DSM-5, neuropsychology
INTRODUCTION
Personality disorders (PD) have always constituted a
major problem in psychiatry, because of the impact they
have on our society. Understanding personality and its
disorders helps us to develop much more sophisticated
treatment guidelines and prophylactic measures. The
DSM-IV diagnostic criteria for PD uses a categorical
approach and this way is not much of a help in an
individualized treatment strategy. This latter assumption
led researchers adopt an opening towards dimensional
approaches. Phenotypic trait personality models have a
better precision in clinical settings then developmental
personality models but are not useful to describe
1
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures. Correspondence: szaszisti2009@yahoo.com
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.
3
MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.
4
Medical Student, University of Medicine and Pharmacy, Targu Mures
Received July 09, 2014, Revised September 01, 2014, Accepted October 03, 2014
2
124
D
47.20
10.8
passed
E
42.06
11.1
passed
C
43.81
10.6
passed
A
45.40
9.41
passed
S
41.85
7.5
passed
Mean
Co
26.4
0
5.25
pass
ed
St
13.5
9
6.03
pass
ed
Ns
15.9
0
5.53
pass
ed
Ha
21.9
5
7.82
pass
ed
Rd
12.6
3
3.4
pass
ed
P
3.77
SD
1.58
Kolmogorov
pass
-Smirnov
ed
Test
Table 2. The mean, standard deviation(SD) and normality test for
the summed scores of the TCI factors. Sd- self-directed; Cocooperative; St- self-transcendent; Ns- Novelty seeking; HaHarm avoidance; Rd- reward dependence; P- persistence
Dimensionality assessment
Table 3 shows the correlation coefficients(r) between the
dimensions of TCI and DECAS.
Sd
D
E
C
A
S
Co
-0.28
0.27
0.34
0.29
St
0.51
0.40
0.49
-0.37
Ns
0.43
Ha
-0.64
-0.72
-0.50
0.45
-0.28
Rd
0.31
0.27
P
0.56
0.45
0.43
DISCUSSIONS
Disposition
We have found no significant correlation between
disposition and self-direction, cooperativeness and
novelty seeking. The moderate positive correlation
between disposition and self-transcendence can be
explained if we analyse the facets of these dimensions. A
person who is acquiescent, insightful, transpersonal,
creative and spiritual will surely have opening for fantasy,
aesthetics, feelings, actions, ideas and values. An
interesting result is the moderate positive correlation
between disposition and persistence. At first sight it is hard
to explain this correlation. The question is how can we
connect persistence and openness in the case of PD. The
best example for a PD with high scores on persistence is
the obsessive-compulsive PD (OCPD). The link between
persistence and openness to values becomes obvious
through this type of PD which has a hypertrophic
superego.
Extraversion
This dimension of the Big five model is known to have
high scores at PDs of cluster B and from the perspective of
the Big seven model cluster B can be characterized with
high scores of novelty-seeking, confirming the positive
correlation we have found in our study. The negative
correlation between extraversion and cooperativeness is
also easy to understand through the cluster B PDs. The
strong negative correlation between extraversion and
harm avoidance can be understood through the cluster C
PDs: persons
who have high scores of warmth,
gregariousness, assertiveness, activity, excitementseeking and positive emotions will definitely have low
scores on the facets of harm avoidance, namely this
persons can be described as optimistic, daring, autgoing
and energetic.
Conscientiousness
Our study has once again confirm the positive correlation
between conscientiousness and persistence both having
high scores in the case of an OCPD.
Agreeabilness
As we mentioned above PDs can be described as low
scorers on agreeabilness and emotional stability from the
perspective of the Big five model and low scorers on selfdirection and cooperativeness from the perspective of the
Big seven model. This fact made our study group expect
positive correlations between these dimensions as we can
see our study has confirmed these correlations finding
positive correlation between agreeabilness and
cooperativeness respective emotional Stability
and self-direction. The moderate positive correlation
between agreeabilness and harm avoidance can be
explained through the component facets of these
dimensions: altruist , modest, tender-minded, people are
usually seen as fearful and shy.
Emotional Stability
Was find to be negatively correlated with harm avoidance
in other words the opposite pole of emotional stability is
positively correlated with the above mentioned Big seven
factor. Persons who are described as anxious, depressive
and vulnerable could be described as being pessimistic
fearful, shy and fatigable.
125
CONCLUSIONS
The study confirms once again the value of the
dimensional approach in understanding normal and
pathologic personality.
The comparative comments of the dimensional evaluation
places a premium on the diagnosis of PDs
Except emotional stability, self-transcendence correlates
with all of the dimensions of the Big five model which was
validated transculturally. Self-transcendence has a major
126
***
ORIGINAL ARTICLES
INTRODUCTION
Suicide is one of the main psychiatric
emergencies and an important public health problem in
most countries around the world (1). The evaluation of
suicide risk is one of the core competencies a psychiatrist
has to develop during his training and professional life.
This evaluation is a complex problem, which involves
assessing and integrating numerous risk factors. To date
there is no clinical or biological instrument that can
accurately predict suicide.
The presence of mental illness is one of the most
important factors that increase suicide risk, being present
in 90% of all suicides (2). Studies have shown that two
thirds of these suicides associated with mental illness are
associated with depression. Nevertheless, the great
majority of people who suffer from a mental illness do not
1
Psychiatry specialist MD, PhD Student, Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, No 10 Berceni Road, Bucharest, Romania. Assistant
Professor, Psychiatry department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; tel: 0724.471.471; e-mail:
am.exergian@gmail.com
2
Child and adolescent psychiatry resident, MD, PhD student Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, Bucharest, Romania; Assistant
Professor, Physiology department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
3
Senior psychiatrist, MD, PhD, Prof. Dr. Al. Obregia Clinical Hospital of Psychiatry, No 10 Berceni Road, Bucharest, Romania. Associate Professor,
Psychiatry department Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Received June 16, 2014, Revised August 18, 2014, Accepted September 08, 2014
127
Ana-maria Exergian, Liana Kobylinska, Maria Ladea: Irritability And Personality Traits As Suicide Risk Factors In
Depression
Suicide risk and impulsivity have also been connected to
aggression. This is both due to the fact that suicide is
viewed as aggression turned inwards and to the fact that all
three of these factors have been linked to serotonin
regulation abnormalities (5, 6, 7).
Therefore this study aims to study the link
between suicide risk and trait impulsivity and trait
aggression. Another hypothesis we want to test is that the
degree of irritability developed during a depressive
episode is related to the overall aggression and impulsivity
of the individual and whether this symptom is relevant in
the evaluation of suicide risk. Also we aim to evaluate the
importance of low tolerance to frustration for the suicide
risk of a depressive episode.
METHOD
This study included a cohort of 103 male
inpatients. It was conducted in the 3rd Department of Prof.
Dr. Al. Obregia Clinical Hospital of Psychiatry in
Bucharest, over a period of two years. Patients with a
diagnosis of Depressive Episode were included,
regardless of the type of mood disorder diagnosed
unipolar depression, bipolar disorder or depressive
disorder due to a general medical condition. Comorbidity
(either psychiatric or somatic) was not a criteria for
exclusion from the study. DSM IV-TR criteria were used
to diagnose the depressive episode. As an independent
outcome variable for the evaluation of suicide risk we
used the type of hospitalization (either voluntary or
involuntary). The involuntary hospitalization was
determined by a commission composed of three
professionals, according to the Romanian Mental Health
Law. The study included only those patients with
depressive episodes for whom the involuntary
hospitalization was decided on the basis of suicide risk.
Each patient was interviewed upon admission
and they also completed two self-administered
questionnaires: the Barratt Impulsiveness Scale (BIS) and
the Brief Aggression Questionnaire (BAQ).
BIS is a self-administered questionnaire
consisting of 30 Likert-type items scored from 1
(rarely/never) to 4 (almost always/always) that evaluates
overall impulsiveness. It contains several subscales that
score attentional impulsiveness (attention and cognitive
instability), motor impulsiveness (motor and
perseverance) and lack of planning (self-control and
cognitive complexity).
The BAQ is a self-administered questionnaire
derived from the Aggression Questionnaire developed by
Buss and Perry in 1992. It consists of 12 Likert-type items
scored from 1 (extremely uncharacteristic of me) to 7
(extremely characteristic of me). The BAQ evaluates
overall aggression as a sum of four categories: physical
aggression, verbal aggression, anger and hostility.
The Hamilton Depression Rating Scale
(HAMD-17) and the Clinical Global Impression Severity
Scale (CGIs) were used to confirm the presence of a
depressive episode and to evaluate its severity.
The data was analyzed using SPSS 16.0 and
Microsoft Office Excel. As the tested variables were
ordinal, non-parametric tests were performed.
RESULTS
The group studied was comprised of 103 male
128
1.Tolerance to frustration
The patients with involuntary admission had a
significantly lower tolerance to frustration than the ones
with voluntary admission (Mann-Whitney U=881.5,
n1=47, n2=56, p=0.003), with more patients having a very
low tolerance to frustration in the involuntary admission
group (fig.2-4).
2.Impulsivity
The impulsivity scores of the involuntarily
admitted patients were higher than those of the patients
with voluntary admission (Mann-Whitney U=805.5,
n1=47, n2=56, p<0.001) , with more patients in the
involuntary admittance group having high scores on the
BIS. (fig. 5-7)
3.Aggression
There was a marginal statistical difference
between the aggressiveness scores in favour of the
patients with involuntary admission (Mann-Whitney
U=1042, n1=47, n2=56, p=0.059) (fig.8-10).
129
Ana-maria Exergian, Liana Kobylinska, Maria Ladea: Irritability And Personality Traits As Suicide Risk Factors In
Depression
4.Irritability
There were no significant differences between
the two groups regarding the irritability scores (n1=47,
n2=56, Mann-Whitney U=1160, p=0.266).
The irritability scores were strongly correlated
with the aggressiveness ones (Spearman's correlation
coefficient= 0.727, p<0.001) , as well as with the
impulsivity scores (Spearman's correlation coefficient=
0.671, p<0.001)(table 1).
Correlations
irritability
impulsivity
aggressiveness
Spearman's rho
.671**
.727**
.000
.000
103
103
103
1.000
.758**
Correlation
.671**
Coefficient
Sig. (2tailed)
.000
.000
103
103
103
.758**
1.000
Correlation
.727**
Coefficient
Sig. (2tailed)
.000
.000
103
103
103
5.Personality disorders
There were no differences in incidence of
voluntary or non-voluntary hospitalization when taking
into account each type of personality disorder (Chisquare=4.806, p=0.187, n=103) (table 2). But personality
disorder comorbidity (taken as a whole) was more
frequent in patients that were hospitalized involuntarily
than in those with voluntary hospitalization (53.19% vs
32.14%) (Mann-Whitney U=1035, n1=47, n2=56,
p=0.035) fig. 11 and fig. 12.
Frequencies
personality disorder type
130
Involuntary
22
16
voluntary
Admission type
absent
38
11
DISCUSSIONS
Apart from the behavioural correlation stressed
by Mann et al., depression and impulsivity seem to be also
linked on a molecular level. Serotonin regulation
abnormalities have been tied to both irritability and
depressed mood (5, 6, 7). The same neurotransmitter has
been implicated in the mediation of other
psychopathological traits like aggression and anxiety (5,
6, 7).
In a study on patients with major affective
disorders, Oquendo et al slightly modified the diathesis
model created by Mann et al. (3), stating that persons who
go on to commit suicidal acts after a depressive episode
tend to develop more pessimism in response to a stressor
and/or have aggressive/impulsive traits (8).
In a review of empirical studies, published in
2001, it was found that impulsivity and aggression were
traits consistently associated with completed suicide (9).
In another study that compared serious and non-serious
suicide attempters, it was found that in the first group there
were significantly higher impulsivity, violence, anger-in
and anger-out scores (10). Perroud et al., in 2011, studied a
sample of patients with major affective disorders. It was
Ana-maria Exergian, Liana Kobylinska, Maria Ladea: Irritability And Personality Traits As Suicide Risk Factors In
Depression
aggression while evaluating suicide risk in depressive
male patients. The degree of irritability was not correlated
with suicide risk in our sample, but this is an area that has
had little research and a definite conclusion cannot be
drawn as yet. A possible new suicide risk factor was
identified as being low tolerance to frustration. Further
research is needed in this area.
REFERENCES
1.World Health Organization. Preventing suicide a global imperative
2014. Available from: http://www.who.int/mental_health/suicideprevention/world_report_2014/en/
2.Harris EC, Barraclough B. Suicide as an outcome for mental disorders.
A meta-analysis. Arch Gen Psychiatr 2005;62(6): 617-27.
3.Mann JJ, Waternaux C, Haas GL, Malone KM. Toward a clinical model
of suicidal behavior in psychiatric patients. Am J Psychiatry
1999;156(2): 181-9.
4.Appleby L, Dennehy JA, Thomas CS et al. Aftercare and clinical
characteristics of people with mental illness who commit suicide: a casecontrol study. Lancet 1999;353(9162): 1397-400.
5.Gonda X, Rihmer Z, Zsombok T et al. The 5HTTLPR polymorphism
of the serotonin transporter gene is associated with affective
temperaments as measured by TEMPS-A. Affect Disord 2006;91(2-3):
125-31.
6.Young SN, Leyton M. The role of serotonin in human mood and social
interaction. Insight from altered tryptophan levels. Pharmacol Biochem
Behav 2002;71(4): 857-65.
7.Carver CS, Johnson SL, Joormann J. Two-Mode Models of SelfRegulation as a Tool for Conceptualizing Effects of the Serotonin System
in Normal Behavior and Diverse Disorders. Curr Dir Psychol Sci
2009;18(4): 195-199.
8.Oquendo MA, Galfalvy H, Russo S et al. Prospective study of clinical
predictors of suicidal acts after a major depressive episode in patients
with major depressive disorder or bipolar disorder. Am J Psychiatry
2004;161(8): 1433-41.
9.Conner KR, Duberstein PR, Conwell Y et al. Psychological
vulnerability to completed suicide: a review of empirical studies. Suicide
Life Threat Behav 2001;31(4): 367-85.
10.Gvion Y, Horresh N, Levi-Belz Y et al. Aggression-impulsivity,
mental pain, and communication difficulties in medically serious and
medically non-serious suicide attempters. Compr Psychiatry
2014;55(1): 40-50.
11.Perroud N, Baud P, Mouthon D et al. Impulsivity, aggression and
suicidal behavior in unipolar and bipolar disorders. J Affect Disord
2011;134(1-3): 112-8.
12.McGirr A, Sguin M, Renaud J et al. Gender and risk factors for
suicide: evidence for heterogeneity in predisposing mechanisms in a
psychological autopsy study. J Clin Psychiatry 2006;67(10): 1612-7.
13.Pompili M, Innamorati M, Raja M et al. Suicide risk in depression and
bipolar disorder: Do impulsiveness-aggressiveness and
pharmacotherapy predict suicidal intent? Neuropsychiatr Dis Treat
2008;4(1): 247-55.
14.Dumais A, Lesage AD, Alda M et al. Risk factors for suicide
completion in major depression: a case-control study of impulsive and
aggressive behaviors in men. Am J Psychiatry 2005;162(11): 2116-24.
15.Apter A, van Praag HM, Plutchik R et al. Interrelationships among
anxiety, aggression, impulsivity, and mood: a serotonergically linked
cluster? Psychiatry Res 1990;32(2): 191-9.
16.Wang L, He CZ, Yu YM et al. Associations between impulsivity,
aggression, and suicide in Chinese college students. BMC Public Health
2014;14: 551.
17.Michaelis BH, Goldberg JF, Davis GP et al. Dimensions of
impulsivity and aggression associated with suicide attempts among
132
***
ORIGINAL ARTICLES
INTRODUCTION
A complex psychopathological reality, that affects not
only the person, but the family and the comunity,
schizophrenia is even nowadays a challenge, both from a
pathogenic point of view and a therapeutic one. While
early treatments aimed to reduce the symptoms, modern
ones are approaching the illness from a broader
perspective, encompassing biological, psychological and
social factors. This is why the concept of quality of life
(QoL) is considered nowadays as a key outcome variable
in schizophrenia.
Although the concept of is broadly accepted, there is no
unanimously accepted definition for it. During the past 30
years, various definitions were proposed, raging from a
focus on psychological aspects as feelings of well-being or
satisfaction, to different living standards like perceived
health, finances, housing or employment status.
Assessing QoL in schizophrenia patients is also a
subject of intense debate in scientific community. The
main area of discussion regards the use of objective versus
subjective ratings. While some argue that reality distortion
1
Seinor Psychologist , Phd. Student, Dr.Gavril Curteanu City Clinical Hospital, str. Louis Pasteur. nr.26, Oradea, 410154, Romnia. Phone No:
0747 274 961, e-mail: atudorei_anca@yahoo.com
Home adress: str. Transilvaniei, nr,27, bl.B53, ap.42, Oradea, Bihor, 410387, Romnia
Received June 02, 2014, Revised August 04, 2014, Accepted September 01, 2014.
133
134
36
distribut
ion
M
29
Education level
Marital status
Employment
status
31
Bachelors
degree
17
Married
Employee
High
school
29
Not
married
40
Retired
39
11
No
employmen
t
13
Vocational
school
14
Divorced
Instruments
Short Form-36 Questionnaire (SF-36)
SF-36 Questionnaire is a generic instrument designed
and tested by New England Medical Center in order to
assess the health status in a large number of medical
conditions. SF-36 is the short form of a 245 items
questionnaire developed within Medical Outcomes Study.
The questionnaire was proved to be useful in monitoring
patients with single or multiple pathological medical
conditions. As a meta-analytical study on this topic shows
(12), it is placed by many authors on a higher position than
other generic instruments used in the assessment of
quality of life in chronic illness. The instrument is a selfadministrated one and it consists in 36 items grouped in 8
scales: physical function (PF), physical role (PR), somatic
pain (SP), general health (GH), vitality (VT), social
function (SF), emotional role (ER), mental health (MH).
The 8 scales are subordinated to two generic concepts:
physical health (PF, PR, SP, GH) and mental health (VT,
PANSS
positive
subscale
PF
PR
SP
GH
VT
SF
ER
MH
Physical
health
Mental
health
.129
-.14
-.089
-.035
-.089
-.258
-.015
-.281
.048
-.254
PANSS
negative
subscale
PF
PR
SP
GH
VT
SF
ER
MH
Physical
health
Mental health
.069
-.048
.236
.365*
-.033
.191
.084
.149
.152
.125
135
PANSS
general
psychopatology
subscale
G1
G2
G3
G4
G5
G6
G7
G8
G9
G10
G11
G12
G13
G14
G15
G16
PF
PR
SP
GH
VT
SF
ER
MH
Physic. health
Mental health
-0.07
-.198
-.263
-.17
-.402**
-.321*
-.082
-.432**
-.13
-.386*
-.242
.021
.023
.168
.004
-.247
-.099
-.091
-.016
.062
-.143
.105
-.101
.084
.308*
.088
.091
-.307*
-.158
-.018
-.075
-.111
-.059
-.066
-.199
-.004
-.213
.067
-.159
-.018
-.081
-.164
-.400**
.055
-.286
-.023
-.125
-.372*
-.002
-.035
-.304*
-.232
-.214
.114
-.069
-0.02
.069
.057
-.257
-.218
-.271
-.078
-.118
-.461**
.025
.06
-.255
-.078
-.267
.166
-.039
.015
.27
.076
-.23
-.247
-.323*
-.111
-.239
-.522**
-0.25
-.027
-.421**
-.053
-.376*
.01
-.342*
-.031
.032
-.096
-.049
-.22
-.401**
-.369*
-.014
-.370*
.168
-.076
-.399**
-.082
-.386*
-.048
-.096
-.224
.097
.103
.207
-.105
-.16
.031
-.036
-.175
.027
.039
-.165
-.053
-.159
.107
-.168
-.037
.147
.074
-.172
-.392**
-.441**
-.417**
-.149
-.421**
.038
-.127
-.442**
-.163
-.475**
-.046
-.178
-.195
.044
.071
-.324*
-.022
-.082
.173
-.072
-.298
-.094
-.036
-.129
-.024
-.152
.169
-.07
.105
.179
-.029
0
-.347*
-.444**
-.376*
-.133
-.415**
.049
-.055
-.454**
-.135
-.438**
-.038
.221
-.205
.052
.071
REFERENCES
1.Voruganti L, Heslegrave R, Awad AG, Seeman MV. Quality of life
measurement in schizophrenia: reconciling the quest for subjectivity
with the question of reliability. Psychol Med 1998;28(01): 165-72.
2.Norman R, Malla A, McLean T et al. The relationship of symptoms
and level of functioning in schizophrenia to general wellbeing and the
Quality of Life Scale. Acta Psychiatr Scand 2000;102(4): 303-9.
3.Browne S, Roe M, Lane A et al. Quality of life in schizophrenia:
relationship to sociodemographic factors, symptomatology and tardive
dyskinesia. Acta Psychiatr Scand 1996;94(2): 118-24.
4.Gallupi A, Turola MC, Nanni MG, Mazzoni P, Grassi L. Schizophrenia
and quality of life: how important are symptoms and functioning? Int J
Ment Health Syst 2010;4(31). doi: 10.1186/1752-4458-4-31.
5.Huppert DH, Weiss KA, Lim R, Pratt S, Smith TE. Quality of life in
schizophrenia: contributions of anxiety and depression. Schizophr Res
2001;51(2-3): 17180.
6.Hoffer A, Kemmler G, Eder U et al. Quality of life in schizophrenia: the
impact of psychopathology, attitude toward medication, and side effects.
J clin psychiatry 2004;65(7): 932-9.
Saarni SI
7Vierti S, Perl J et al. Quality of life of people with schizophrenia,
bipolar disorder and other psychotic disorders. Br J Psychiatry
2010;197(5): 386-94.
8.Wilson-d'Almeida K, Karrow A, Bralet MC et al. In patients with
schizophrenia, symptoms improvement can be uncorrelated with quality
of life improvement. Eur Psychiatry 2013;28(3): 1859.
9.Gaite L, Vzquez-Barquero JL, Borra C et al. Quality of life in patients
with schizophrenia in five European countries: the EPSILON study. Acta
Psychiatr Scand 2002;105(4): 28392.
Ritsner M, ModaiI, Endicott J et al.
10.Differences in quality of life domains and psychopathologic and
psychosocial factors in psychiatric patients. J clin psychiatry
2000;61(11): 880-9.
11.Gee L, Pearce E, Jackson M. Quality of life in schizophrenia: A
grounded theory approach. Health Qual Life Outcomes 2003;1(31). doi:
10.1186/1477-7525-1-31.
12. Garratt A, Schmidt L, Mackintosh A, Fitzpatrick R. Quality of life
measurement: bibliographic study of patient assessed health outcome
measures, BMJ 2002;324: 1417-1.
13.Kay S, Fiszbein A, Opler L. The Positive and Negative Syndrome
Scale (PANSS) for Schizophrenia, Schizophr Bull 1987;13(2): 261-76.
14.Fitzgerald PB, Williams CL, Corteling N et al. Subject and observerrated quality of life in schizophrenia. Acta Psychiatr Scand 2001;103(5):
387-92.
15.Eack SM, Newhill CE. Psychiatric Symptoms and Quality of Life in
Schizophrenia: A Meta-Analysis. Schizophr Bull 2007;33(5): 1225-37.
***
137
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139
acknowledgements.
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same product names should be used throughout the text (with the brand name in parenthesis at the first
use).
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Information from the Introduction or Results should not be repeated unless necessary for clarity. The
discussion should also include a comparison among the obtained results and other studies from the
literature, with explanations or hypothesis on the observed differences, comments on the importance of
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in the future.
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(Ionescu I, Popescu I, Georegscu I et al).
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Abbreviations.
Examples:
- Reference to a journal publication:
Vrati R, Matei VMI. The crisis centre in Romania. Eur J Psychiat 2002; 29:305-311.
Reynolds CF, Frank E, Perel JM et al. Treatment of consecutive episodes of major depression in the elderly. Am J
Psychiat 1994; 151(12):1740-3.
- Reference to a book:
Vrasti R. The crisis centre in psychiatry. Toronto, London: Academic Press, 1993, 26-52.
- Reference to a chapter in an edited book:
Schuckit MA. Alcohol-Related Disorders. In: Sadock BJ, Sadock VA, Ruiz P (eds). Comprehensive Textbook of
Psychiatry. Philadelphia: Lippincott Williams and Wilkins, 2009, 1268-1287.
The placement of the italics, punctuation and the general aspect of the text format must comply with the rules
mentioned above. This is a mandatory and eliminatory condition.
INSTRUCTIONS FOR MANUSCRIPTS SUBMITTED IN ELECTRONIC FORMAT
The text should be edited in Word for Windows.
1. Use as few formatting commands as possible:
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141
Index Of Authors
142
ROMANIAN JOURNAL
OF PSYCHIATRY
CONTENTS
EDITOR-IN-CHIEF:
CO-EDITORS:
SPECIAL ARTICLES
& Somatic Co-Morbidities and Frailty in Patients with Mental Disorders 110
Mihai V. Zamfir, Anca I. Talaman, Gabriel I. Prada
REVIEW ARTICLES
&
115
118
ORIGINAL ARTICLES
& Comparative Dimensional Approach of Personality Disorders
Through the Models of Big Five and Big Seven
Istvn Zs Szsz, Adrian I Horvath, Tudor Niretean, Anna M Tth
124
& Irritability and Personality Traits as Suicide Risk Factors in Depression 127
Ana-Maria Exergian, Liana Kobylinska, Maria Ladea
&
138
INDEX OF AUTHORS
142
Romanian Journal of Psychiatry and Psychotherapy is indexed in the international data base Index
Copernicus Journal Master List, starting with 2009.
APR
Dan PRELIPCEANU
Drago MARINESCU
Aurel NIRETEAN
ASSOCIATE EDITORS:
Doina COZMAN
Liana DEHELEAN
Marieta GABO GRECU
Maria LADEA
Cristinel TEFNESCU
Ctlina TUDOSE
Executive editors: Elena CLINESCU
Valentin MATEI
STEERING COMMITTEE:
Vasile CHIRI (Honorary Member
of the Romanian Academy of
Medical Sciences, Iai)
Michael DAVIDSON (Professor, Sackler
School of Medicine Tel Aviv Univ.,
Mount Sinai School of Medicine,
New York)
Virgil ENTESCU (Member of the Romanian
Academy of Medical Sciences, Satu
Mare)
Ioana MICLUIA (UMF Cluj-Napoca)
erban IONESCU (Paris VIII Universiy, TroisRivieres University, Quebec)
Mircea LZRESCU (Honorary Member of the
Romanian Academy
of Medical Sciences, Timioara)
Juan E. MEZZICH (Professor of Psychiatry
and Director, Division of Psychiatric
Epidemiology and International
Center for Mental Health, Mount
Sinai School of Medicine, New York
University)
Teodor T. POSTOLACHE, MD (Director,
Mood and Anxiety Program,
Department of Psychiatry,
University of Maryland School of
Medicine, Baltimore)
Sorin RIGA (senior researcher)
Dan RUJESCU (Head of Psychiatric Genomics
and Neurobiology
and of Division of Molecular and
Clinical Neurobiology,
Department of Psychiatry, LudwigMaximilians-University, Munchen)
Eliot SOREL (George Washington University,
Washington DC)
Maria GRIGOROIU-ERBNESCU
(senior researcher)
Tudor UDRITOIU (UMF Craiova)
www.romjpsychiat.ro