Motivation of topic:
The difference between paranoid schizophrenia and delusional disorder is sometimes challenging, to establish the clinical diagnosis being useful: age of debut, following the longitudinal evolution of the patient, deterioration of social functioning, as well as pathological expression in cognitive and perceptual level.
Present paper present a case report, which raises the issue of differential diagnosis, because of the long period of time during which patient did not receive psychiatric care, has refused medical treatment but, however she kept the social functioning to prior achieved level, having minimum emotional and social support from family and coworkers.
Psychiatric interviews, psychodynamic interview, map of life, monitoring the psychiatric evolution under antipsychotic treatment, psychological exam, neuroimaging examinations (CT, EEG), investigation the hormonal functions.
Princeps factors which influence diagnosis (in terms of paranoid schizophrenia support) depend on: age of debut, the mental automatism syndrome, lack of verra hallucinations, presence of lookalike illusion. Results: debut around 35 years of age, lack of cognitional disorganization, predominance of up to two or three delusional themes, fairly good social functioning, the absence of collateral family history, are positively prognostic factors. Among the elements of unfavorable prognosis are: lack of insight ability, imperviousness to criticism and counterarguments, treatment non-compliance, despite established therapeutic relationship.
Presence of mental automatism syndrome, lookalike illusion, as well presence of symptoms for a long time prior to hospitalization, support the paranoid schizophrenia diagnosis, ever since the first hospitalization in psychiatry.
Keywords: Paranoid schizophrenialookalike illusionmental automatism syndromedelusional ideationaltered social functioning
The current episode debuted over several days, the patient reaching highs of psycho - motor agitation, accompanied by hetero-aggressiveness, a condition characteristic of choleric mania and psychotic productivity at ideation and perceptual level. Our meeting takes place one month after the onset of the second non - voluntary hospitalization of the patient, when it reached a euthymic to affective flattening status, keeping a minimal sensitive interpretative pathology and disorder at the level of the Gnostic functions.
Medical / somatic records
From medical and somatic records we can identify the following: - perforated duodenal ulcer (same disease that dictated father’s death), C stating that the pathology debuted by nervous system disorder - appendicitis.
Interpretation in the psychosomatic register
The moment triggering the disorders combined in the neurological, psychological and somatic register interfered in the patient’s life at the age 5 and half years, with the loss of his father. As a defense mechanism, of denial of the pain, in the adult occur cleavage / fragmentation of the entire functioning of the patient:
"I was playing with his infusions after he died"
. During the interview, C shows a need of confirmation from others, as a cry for truth. In fact, their own refusal to acknowledge her own pain:
"I would like to ask her to, my mother, if you can, what brought me here... That you should do! You should do something to show me the truth!"
denotes an emotional resonance inability.
The patient has a
symbiotic-type functioning level
. Therefore, the dissociated psyche of the
concerned person, it is always in connection with an "other" à
"My child has the same soul like me, as I am his mother... My brother has the same soul like me..."
The careful register in which mystical reasoning appears and of which are extracted the contents of ideas affirmed in the interview, come from a patient’s need for belonging:
"What do you think about my soul, is it a gift from God? When I was pregnant in 3 months with Alexander, is when I first saw Jesus. Since then I knew I was having a boy! I thank God that I have Alexander!"
Mrs. C, at a latent level, remains in touch with his father through the various connections with males with whom she interacts in her ordinary life, in various contexts:
"Mr. Căpăţînă, if he would be here, present... I would love to look him in his eyes and see what he dares to tell me... I liked by
gynecologist physician, with whom I gave birth... ".
During the interview, the patient declared:
"I took a rest leave, which in fact, I spent in the hospital..."
She dissimulated her own acts of psychomotor agitation manifested in her family environment, recognizing that she agreed to come to the hospital brought by the Ambulance so
"the little one ceased having panic attacks"
Elements of psychiatric diagnosis
of type: slight suicidal disruption mystical delusional ideas visual hallucinations disorganized articulation circumstantial speech
hypoprosexia (inability of concentration, stability and selectivity of attention) alogia rough diminished spontaneous movements, despite overcompensation by an aggressive attitude low facial expressiveness, empty looking monotonous voice moderate eye contact.
Adjacent elements belonging to a broader
general symptomatic area
would be: *** use of humor as a defense mechanism *** language with bizarre subtle notes *** inner restlessness *** moments in which C appears in a flawless contact with a tough hyper-reality, which is his own life.
*** functionality marked on interpretativeness: "I felt mentally tired ... I recognize a good-hearted man, by voice. And now, if I had the power, I would revive my father, logically, right? I prefer not to bear as many as I bear here in the hospital... Even though I am not that kind of human who likes to make have acquaintances all over the place... "
Stress - voice pattern. inputs in the patient’s vulnerability body build:
father’s death at an early age the fact of being raised without a father, the mother having a relationship of cohabitation (only occasional presence of father figures in his entourage) health problems of the mother and brother (both blind, elderly, homebound mother) imminence of non-employment fatigue caused by job (long hours job, without breaks, routine work that requires attention, dealing with money) precarious financial status conflicts with former concubine, the father of the child, who wants the minor’s custody, accusing A of psychiatric disorders real difficulties in material and affective plan to raise her child alone.
Mental examination of the current condition
Attire proper to age, place (hospital), accessories and make-up in normal
standards; wide view, inert eyebrows, expressing anxiety.
kept visual contact.
good temporal - spatial, self and allopsychic orientation.
she understands the meaning of proverbs, attention and mental calculations are possible, but with embarrassment (attention: for the countdown from 100 decreasing by 7, after the first calculation she could no longer concentrate, she having the profession of account).
Disorders of form
àescape of ideas, subjective feeling that her thoughts are running away, incoherence, but not in the phrase, but for the entire speech.
Disorders of content
à we found a prevalent ideation related to her child, to the remembrance on his birth and relationship with her former concubine. Ideation of mystical colorfulness, of persecution and injury (currently, insufficiently substantiated). For the purpose of coping mechanisms, an outside projection of the place of control, by her inability to give a coherent and consistent sense of all that happens to her:
"Call Căpăţână, so he tells you!"
lasts 17 minutes, it is suddenly interrupted and do not indicate a major affective episode (depressive or manic) nor psychotic elements. They, most likely, were totally or partially restored (the patient dissimulates and avoids key questions).
We notice here elements of mistrust, suspiciousness, irritability, C is on guard and feels threatened by the interviewer, she hides her anger and keep a straight, formal tone. (Tudose, 2011) She has hard feelings, she wants revenge, talks about violence in an unbiased manner, she feels threatened, manipulated, passes over the responsibility to others and has moments of appellant conflictuality, impulsivity, negligence and disclaimer.
along with elements in the specter of intransigency and paranoiac strictness
) which, in the current context, seems to be the pillars, the anchors on which the patient can stick to a potential social support network in order to prolong family and professional functionality. Such salient features would be: rapid changes of emotional register (superficial emotions, which makes it difficult to empathize with the patient) self-dramatisation à impressionistic style and lack of details, the pleasure of being the center of attention, to let herself filmed, the need to ask for things and ask personal questions to the interviewer (considering the relationship as being closer / more intimate than would be the case). She tries to seduce and gain sympathy / empathy (asking about
"her tiny soul"
expecting to be showed appreciation and reciprocity).
Epilepsy crises that stopped after pregnancy carry a
differential diagnosis from the converse crises
, typical to a psychological condition called "hysteria" in the classical sense, psychoanalytic with all the necessary psychotherapy: (Enachescu, 2008); emotional immaturity, repressed sexuality, non-attainment of the genital phase (in psychosexual terms), feelings of anger, inability to emotional self-content and physical manifestation of emotions.
The fact that he had gastroduodenal ulcer suggests a psychosomatic condition that involves aggression, self-dissatisfaction, desire and permanent inability to please others. Anger can transiently be turned against the others, but as a projection, the bottom is to self-justification and, hence, we can transform this picture in one of uncertainty and anxiety. (Ionescu, 2006)
Objects / places with affective investment
▪ father’s perfusions (symbol of the moment reaching the life / death, under the equivalent of a
game for children)
▪ own clothes ▪ child’s toys ▪
(given to him by a potential psychotherapist) ▪ medical office books / magazines (as desire for attachment, aggressively expressed) ▪ grandmother’s garden.
C lives in a relatively harmonious family atmosphere, by the age of 5 when his child’s happiness
is interrupted (Lazarescu, 2010): father dies in full Oedipal phase, remaining an irreplaceable emptiness inside her, even worst deepened by the relationship with her mother and her lover. Perhaps not coincidentally, she manifests times of urgent desire that her father live in a real plan:
"I would revive him, logically, right?"
, because in virtual sense, he has not passed away and he is practically immortalized in the phrase à
"I have pictures"
, adapting the truth to Mrs. C’s acute needs.
She cried for the truth, but at the same time, she owns
mechanisms of denial in the service of repression
"I prefer not to remember","I prefer only THAT!"
She pulls a defense curtain, hosting a psychotic world where she prefers to do things by her own will, as in childhood, when her
"Father was stealing flowers for me and he was paying for fines...".
C’s fine now is taking the shape of the hospital, psychiatrists, and therapists and, in particular, medication.
From the patient’s lack of accountability side, clear-cut limits come to the fore:
"I do not want to remember"
"I do not want to cry"
, as a refusal to feel the pain.
Symbolic explanations of c’s psychotic functioning
"Then I first saw Jesus and I knew I am having a boy!"
→ visual hallucinations, about the patient is storytelling, making the connection between her pregnancy and the occurrence of a
"wound down there"
à cause attributed to the fact that the father did not give the doctors anything.
"Căpăţână has not given enough bribes..."
à The idea for the illegal, immoral, in fact, mirroring the model mother, and of C, to have a
The patient feels lost, rooted out and perceived control over situations as somewhere outside her, except in the framework where he is:
"Ask him!", "You also do something!".
She tangentially understands sayings like:
"The apple does not fall far from the tree"
, responding that it means:
"The mother and the baby"
, statement from where multiple mirroring and identity elements with her son arise:
"Alexander has the same soul as his mother"
"My brother has the same soul as mine"
. Her childhood friend is
, name that she repeats all over again and that she gave to her son, from the need to belong to something dear and the desire to support one another.
C literally cannot rely on any of her family members.
"My brother has eye glaucoma"
"My mother is old and is hit in the leg..."
Like a sort of continuation of her mother’s life, who is
, she says laughing:
" The lady in the yard told me that I will live up to 90 years!"
It’s grandparents yard, where he grew up and felt happy.
C’s need to share clothes implies two aspects: *** transfer of the mother identity
*** deepening the role of sister → brother.
During the interview, she searches inside her pocket (as a child hiding something valuable) or a mother who wants to give the
a candy: the
with the phone number of of the therapist. Again, C emotionally sticks something tangible. Blue is the symbol of sensitivity, of detachment, generosity and also the color of
, which she wants back:
"I would like to recover the place where I grew up with my grandmother, who even now I sometimes see in front of my eyes..."
The patient’s mystical side is similar to a kind of justice, one way to control from the outside, a form of asking the Divinity for approval, confirmation, for the truth:
"My soul is a gift from God",
a form of gratitude à
"I thank God that I’ve got Alexander!"
Father → brother → son → concubine → Gelu → the gynecologist → Mr. Ciprian ≡ C’s attempt to
"compile" / recompose her father
, taking from each the elements of similarity, which he used for trying to survive emotionally.
C is fervently asking us to
be both heard - "He went home, I stayed here...".
Despite the circumstantial speech, the patient seeks for evidences,
with legal papers
. She has a "hic et nunc" impatience -
"Now if it would be possible!"
and is manifesting pleasure (a pathognomonic sign of schizophrenia) to remember and expose the person’s name. To the question about collateral family antecedents, the patient tells about her mother aged 84 and about her inability to visit her at the hospital.
is the major mechanism that C uses, despite the fact that it
takes the appearance of repression
in phrases like: "I’d rather not remember."
symbolizes so that he was both the head of the family and a sort of stubbornness, bitterness, rigidity of the patient, relative to his position in her psychic economy. (Enachescu, 2007). C’s repeated entreaties take the form of hard persuasions, even if inside them one can feel the impenetrability side in proven reality. Minimization of what happened
("There were just some discussions in the family, so to speak...")
is another defense mechanism. The colleague,
called Nicoleta, signifies the patient’s need to anchor herself to the world, the need for immutable, which is majorly impaired in patients with schizophrenia. The mechanism is somehow opposed to the Fregoli illusion or is put into play especially to prevent such possible pathologies to the perceptual level. (Trifu, Petcu, 2011); "
says C continuously, showing how control is out there somewhere. Someone else takes power and handles things to come off well.
In an exclusively psychiatric perspective, we note that: the lack of sleep, hyperactivism, increase of the number of cigarettes smoked, excessive finance charges, verbose, subjective feeling that her thoughts are running in her mind,
. (Athanasiu, 1998). C is seeking for "one function", uniqueness being an important milestone of her psychic life. The apotheosis of the moment,
"I want it right now!"
is coupled, in the same order of ideas, with diverted tasks to
"I would like my baby to solve them out" and "That’s ALL I prefer!"
. C is interested in good-hearted people, of large generosity and according to the expression "to have at one’s will", on discretion and for her will. Where
there is no limit for frustration
. She talks a lot about "mother and child", beyond which one can feel her sensitivity and dysphoric appearance. The blue paper on which she puts down the therapist’s phone number becomes the emotional support of interpersonal contacts. The narcissistic gemelarity
("My boy has the same soul like mine")
entails her to gift away clothing and toys. It’s kind of a regressed way to satisfy herself through the metaphor of an
from mother à child.
"Everybody knows me and everybody loves me!"
easily turns into irritability like:
"I, in my view, I said what I had to say. Now, you decide!".
Statements continue with the remembrance of her father’s death (which occurred when C was 5 years old), from childhood memories, in relation to which the patient has "photo"-type answers: everything was or is
, which marks the permanence of suffering, trauma, but also father’s capturing and immortality. When simply asked:
"Do you have memories?"
, the patient replies:
"I have pictures!"
"If I had the power, I would revice him!".
Her father had an ulcer, but
"the doctors had the wrong surgery and therefore he died."
Dad gave everything for C, he stole flowers and paid fines. The symbolic significance of the reported facts is only seen by us. The patient is in a quasi-permanent symbolism, when she states how when she was 5, her father gave her his part, allowing her
to handle money
After talking about her father’s death, C turns to the
principle of equality and fairness
"My mother raised me and my brother. I’ll help her until death. The time comes for all. No man has everlasting life"
. Although, behind the statement "photo" one can feel the denial. It is an effort to regain normality. Any patient with psychotic functioning, and, moreover, any normal person, is embedded in the unconscious - both personally and collectively - the
idea of death
(Enachescu, 2007), and most
to cope with. Subsequently, C talks about her mother’s lover, with respect and he calling him
(he was married with children and an important social position) and raising the cohabitation to the rank of "as much as I deserve". In parallel, she states several times the desire to
rebuild her life
and senses coincidences between hospital name
Dr. Alexander Hospital
"This is also my son’s name!"
. The feeling of reflection and identity that she has with her son, she also experiences with her girlfriend, but also in the relationship with her brother, who has the same soul, the same as hers. Gemelarity is typical of a primitive functioning, a mental and emotional small age, although patient is fantasying about
eternal life and youth without old age and life without death
"O lady from the yard told me I will live up to 90 years!"
Childhood and grandmother’s yard, the
, this is what she wants to recover back. After her father’s death, C has her first epilepsy crisis, at the age of 5, in the respective psycho-traumatic background:
"I remember playing with his perfusions, which remained there after he died"
. C had epilepsy crises throughout her childhood and beyond, until
she gave birth to Alexander. Since then, she didn’t have any crisis
. Once given
life back for life
, this caused C to stop crying. Therapeutic intervention:
"It means that you loved him a lot!"
expresses, in fact, the enormous pain lying unconsciously. C says that she had ulcer, the same disease as her father. After that, she relapsed into a mental illness to save herself from a similar death.
The patient reports the moment of losing her virginity with details of the type
"13-levels block of flats"
, which demonstrates the need for concrete facts -
"I did it without the knowledge of my mother, but she would have forgiven him by now..."
. C. strives to highlight the identical reality to that of her mother. She
feels an acute need for truth
, achieved at the cost of denying and an infantile projection:
"I do not want to remember Căpăţînă, now you should talk with him"; "And my baby to become
and to heal her again, as he once, a long time ago, healed her mourning after the death of her father.
During pregnancy, in the third month, she reported visual hallucinations located at the boundary of subcultural normality:
"It’s when I first saw Jesus then I knew I was having a boy!"
. After birth, she remained with a wound on the cervix, the reasoning, in somatic perspective, of a maternityrelated trauma. By projection, one can identify a residual idea of type:
"This happened because Căpăţînă not given sufficient bribe".
C to get something you deserve
through an illegal manner, similar to having a lover.
Patient’s ideation is of expansive coloratura, when she states:
"I will help my brother to regain his sight"
"Căpăţînă should confirm you that my child was shot in Neurology too!"
. Further, currently C wants to have the
power to change reality
"I love Gelu. I told Alexander I want gelu as the biological father for him"
. For her, the clothes symbolize skin and the repetitive claim
should talk to Căpăţînă" becomes a parable for:
you should do something too, to show me the reality
, that C feels she cannot test well enough.
The patient is reporting to her own son as to a baby. She is in constant search of the father and of the relationship of brotherhood, which seems to repeat in the relationship with her own child. Offering things as a gift is reminiscent of the relationship sibling - sister and to the idea of
. The anxious attachment takes the form of a desire of anchoring / need for permanence in a relationship with a man.
I love my baby
is a metaphorical point as a spelling sign, C reporting to her son as to the good and healthy side inside herself. We wonder where the resentment produced from humiliations incurred for years has dissipated.
C’s background is punctuated by: her father’s death, epilepsy crises, cohabiting relationship (which changes the feeling of durability of a marriage) and the somatic suffering around her. She stays in hospital for
others to do something
, dominated by the helplessness and victimization. Otherwise, she would not be credible. She has an indirect contact need and an indirect need to be confirmed; including the validation of the fact that she does not react well to the environment. She has unrealistic expectations, while her speech is peppered with the idea of mirroring, with sticking to the others. She and her son are interchangeable, as if petrified at the age of five when C’s father died. In her, everything is a defense and she knows how to put very firm limits:
"I do not want to remember"
"I do not want to cry"
. She is a
patient in terms of accountability. The masculine figure in her life is embodied by: father, son, concubine and brother. Her mother is the one who raised them well and worked hard, then she only appears later in C’s stories at the age of 84, old and ill. The rest is missing. The men - those who are blood relatives (her father, son and brother) are
, while the concubine, Căpăţână is
. Although at job she pulls through, C has a broken speech, without a continuous melodic line.
All experiences from the age of five are shorted and discharged in epilepsy crises. The relationship with her mother and the latter’s lover is a problem in itself and also a challenge for the former C girl, in terms of
building her happiness
. Her father died in full oedipal period and the emptiness left inside her is worse than a conflict. The
subsequently paid fines
suggest a difficult Oedipus. (Enăchescu, 2007). The maximum moment in which the patient was in contact with the pain is represented by the symbol of the
game with the perfusions, an image that brings together life and death
and bears the
mark of ambivalence
. The wound on the uterus, located in the "middle of femininity" of C is brought to be repaired in psychiatry. Against the child, between him and her illness, C knows how to raise a protection wall. Alexander is good and generous. The need for others to be heard is a response to:
Take action, do something, let a whole world hear me!
An interview located at in-depth psychodynamic level stands the risk deconstruct such a patient after 45 minutes. The reactions aroused in others reunite the following experiences:
emptiness, confusion, fear, violence
. For us, mercy is more thought than felt. C seems rather flattened, making others around her believe her defense a problem with honesty, when she stereotypically states:
"Ask the others!".
We ask ourselves where the problem lies, because when she becomes agitated and aggressive, she defends from the
that at some point
become too much
. In this context, flattening becomes a huge repression of despair.
There are levels to feel: 1. Feeling as coming
the patient; 2. Feeling
the patient and 3. What we think she feels.
C transmits us a paradox: an emptiness we do not know if it is much more emotional or much more mental; a violence of emotion and a violence of behavior; what she feels / what another
person thinks she feels
. In others she leaves the
impression of a wall
. Is there a window? The window has broken and parts of it were dissipated in all the characters. The contents where she may not enter are kept for storage in good characters. The psychiatrist who interviews her expresses her sensory availability by means of a warms voice. C shuns cognitive tests and mnesic - prosexic test, which risk exposing the insight of the illness. She searches in video camera a container, in the winnicotian sense of the word. The video camera is causing the following reaction on her: I can feel what I feel, if the other send me a feedback. Give me
Under the administration of an incisive antipsychotic in a maximum dose, together with the reduction of the antidepressant dose, the patient appears emotionally depleted, as if a high dose of AP (which tried to annihilate perceptual phenomena) blocked the externalization of emotions. At a superficial level, it seems to take that suggestibility increased, which if it confirms during developments of coming days, would raise the risk of cathatonisation. In the dynamics of a possible differential diagnosis, at body level the sensation of impregnation and the tendency to fast are identified (below 18 mg Invega).
When attempting to be placed in contact with her own affects, she responds directly that
"her life would be all sad, with or without voices"
. Sadness seems more thought and affirmed than lived, as if the antipsychotic has strengthened some operable efficient schemes, which helps her to operate in a superficial attitudinal plan. At this level of daily living: she notices some aspects of reality, such as:
"You were always nice to me!"
; she falls sporadically in connection with men whose intent she manages to identify, but not to also mentalize; she knowns to compliments the persons around her, to preserve a minimum of
She creates a feeling of "white silence" and the need for the specialist to give her time and inside space, where she would like things to happen. Perhaps not coincidentally, the patient builds her own metaphor of actual psychotic status, in which
she is convinced that there is no present, only past and future.
In Auerbach’s explanatory perspective, it is the patient’s inability to seize this
(awareness of the present moment; it’s those moments that tear down any possible
and the human being is in direct contact with her feelings, coming on all sensory channels).
For the beginning, demolition of dissociation mechanisms and procurement of continuity in time (the minimum for those 10 seconds) would be a goal. The lack of continuity creates inside the interlocutor the feeling of emptiness that is the end of the projection of mixed thoughts.
Increasing the dose of antipsychotic and decreasing the antidepressant dose raised the barrier and corseted E. in terms of those external things that should reach her. It stayed functional to a conventional level, where the
patient does not actually chooses between I want / do not wants, but she can give the impression of choice
, similar to a primitive level of functioning in which caresses and compliments heal, but are not understood. It is a short-circuit in mentalization, when E. can take an information, but beyond that level she does not know how to use it and can not bind it to anything else.
When attempting a reconnection of affects with cognition,
are obtained, exactly when the patient would feel the symbolic significance of things
("There are some people who laugh at you?" / "What can I say, doctor... .?!! ").
The feeling discharged around her so that of the annihilation, of shell (lack of internal understanding and consistency of things, the wall where any energetic effort from the others to give back to her stops!). However, C is the one that puts the mechanism inside the game: I.
I do not deserve, I am insignificant and there is nothing good for me anymore...
II. The reaction aroused in the others, to mobilize to give her back.
III. Her reaction of symbolic rejection, that nothing is enough / consistent, to fill her, to
feed her, to narcissistically repair her.
At present, she is so fragile that if she feels the "risk" that she could receive what is offered she could
. The extreme caricature of this situation is the so-called patient’s urinary incontinence, manifested not in nocturnal episodes, but exclusively during medical visits.
It remains active the struggle between the
world of internal voices
, that has not got enough power to capture it. The complimentary level offered is of an operational schemes, used as an adaptive mechanism with minimal emotion involved. The question remains, "Why?" and "For how long?" she will need the hallucinatory world!
She is defensive, and from here, the feeling she is not trusted. To believe a patient with a so primitive behavior means
. Once reached this goal, from the patient’s unconsciousness a
is revealed. For C, the hospital is worse than death, her defenses against this institution being built with her father’s death, at which time C was somatically, psychologically and psychosomatically affected, which further on allowed the belief that the somatic kills. In a specific form, C has powers over this institution: she manipulates and she is brought her child.
Symbolically, the hospital is a tribunal
invested with the power of punishment, salvation or remittal, someone who "has the bread and the knife" in her hands, the place where good and evil comes from. Her sadness is drowning in small things, recalling the
anguish man in Sadoveanu’s novel
, psychoanalytically transferred into a melancholic cruel Superego (apotheozed in the game with her father’s perfusions).
The speech is circumstantial, with excessive details, denial, resistance,
impression, with successful highlight of the distinction between: good / evil, love / hate. C’s empty look mimes the arrogance hiding the fear. For her, the control of things comes from outside, so that in the mystical side (God - the divine power and Jesus - the son) translates her lost father.
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