Psychiatry: A Course of Lectures - V. S. Bitensky 2004

Personality and behavioral disorders in adults, adolescents and children

Previously, these disorders were known as «psychopathies.» Rooted in psychiatric science, this term became firmly established in everyday lexicon and carries a somewhat derogatory connotation. For this reason, modern disease classifications use the term that appears in the title of this lecture. A BRIEF HISTORY OF changing Perspectives on Various Forms of psychopathies is provided in the table.

This group comprises disorders characterized by deeply ingrained and enduring behavioral patterns that typically span several domains of the personality and are accompanied by personal and social disintegration. In other words, The basis of Diagnosis is the Gannushkin–Kerbikov triad: the totality of pathological character traits, their stability, and the resulting maladaptation in social life. These disorders emerge in childhood or adolescence, but they persist and, most importantly, are diagnosed in adulthood. Each condition within the group is classified by its dominant behavioral patterns. Let us examine them, while also focusing on diagnostic criteria and certain therapeutic approaches.

Paranoid Personality Disorder Characteristics

To diagnose a paranoid personality state, a clinician must identify at least four of the following traits or behavioral patterns in the patient:

— persistent dissatisfaction with other people and a conviction that they are doing everything «wrong»;

DSM-III-R: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, anxious (avoidant), dependent, obsessive-compulsive, passive-aggressive personality disorder, and personality disorder NOS.

— collecting grievances and injustices, naturally directed primarily toward oneself;

— self-righteous, litigious behavior, coupled with grumbling, quarrelsomeness, and uncooperativeness;

— transient ideas of reference, i.e., completely unfounded ideas about «conspiracies» and The formation of various coalitions directed against the patient, which subjectively explain failures and the generally hostile attitude of others;

— absolute confidence in one’s own objectivity and the rationality of one’s actions;

— a tendency to form overvalued ideas, the most prominent of which is the «idea of the exceptional significance of one's own personality»;

— excessive sensitivity to setbacks and rebuffs;

— suspiciousness and distrust of people, along with a tendency to shift responsibility onto others;

— in personal life, persistent suspicions regarding a sexual partner's fidelity and interest in sexual contacts «on the side».

Table of Classifications of Personality Disorders (Psychopathies)

This personality disorder is extremely difficult to treat, and its «bearers» are notoriously hard for their micro-social environment to tolerate, as they form factions, coalitions, and opposition—primarily against management, with whom they are rarely satisfied. The life motto of paranoids is: «Whoever is not with us is against us!» Among Treatment Methods, individual psychotherapy is preferred, as pharmacotherapy has proven largely ineffective.

Schizoid Personality Disorder Characteristics

It is no coincidence that the name of this disorder resembles Schizophrenia, as schizoids share certain traits with schizophrenic patients. However, this is merely a superficial resemblance. Schizoid personality disorder and schizophrenia are fundamentally different conditions that never transition into one another (we will discuss the so-called borderline personality disorder below, which is even closer to schizophrenia in its manifestations, yet it too is not a developmental stage of the process, but an entirely independent diagnostic entity).

Character traits that distinguish schizoids:

— in their relationships with people, what stands out is emotional coldness, indifference to the feelings of others (reduced capacity for empathy), and detachment;

— schizoids exhibit a diminished ability to express warm feelings or anger toward those around them; in such cases, the person is said to have a blunted affect;

— outwardly, they remain indifferent to praise or criticism from others;

— in their intimate lives, they show a reduced interest in sexual experiences with other people (taking into account age and cultural factors, of course);

— they almost constantly prefer solitary activities; there are very few activities capable of bringing them joy—typically, these involve self-absorption and formalizing contacts with their environment, such as programming;

— projective tests easily reveal excessive absorption in fantasy and, even more so, introspection;

— their lives are typically characterized by a lack of close people (at best, no more than one) and trusting relationships, and even an unwillingness to have them;

— maladjustment is usually caused by an inadequate consideration of social norms, frequent departures from them that are not of a demonstrative nature.

Schizoids are sometimes divided into sthenic (a typical image of a sthenic schizoid is the "godfather" of a criminal syndicate who plans and organizes sinister crimes through his henchmen while remaining indifferent to The Fate of both the victims and his "like-minded peers", preferring to stay "in the shadows", meaning he is not inclined to demonstrate his power and abilities) and asthenic (sensitive, "mimosa-like", who can experience injustice toward themselves or others very deeply while remaining outwardly cold and detached). The latter type of schizoid "breaks down" much faster, i.e., becomes decompensated under METABOLISM/18.html">The Influence of stressors.

Treating schizoids is a difficult and thankless task. It is necessary to find a subtle approach to a personality with schizoid traits; such a patient cannot be imposed any action program, since their thinking is always independent and unusual for the microsocial group to which they belong. For the resocialization of a schizoid, an individualized behavioral program of social activation is used. Pharmacotherapy is ineffective.

Antisocial personality disorder

Its bearers include a significant proportion of criminals who have committed particularly cynical and bloody crimes. To diagnose antisocial disorder, the individual's condition must meet at least three of the following traits or behavioral patterns:

— callous unconcern for the feelings of others, incapacity for empathy;

— gross and persistent irresponsibility and disregard for social norms, rules, and obligations;

— extremely low frustration tolerance and a low threshold for aggressive behavior;

— incapacity to maintain enduring relationships with no difficulty in establishing them;

— absence of guilt or inability to learn from negative life experience, especially punishment;

— marked propensity to blame others or to offer plausible rationalizations for behavior that has brought the individual into conflict with society;

— persistent irritability.

In treating this disorder, it should be taken into account that patients are incapable of establishing stable empathetic relationships. A group of understanding and benevolent peers are the circumstances in which a psychopath may wish to change. Pharmacotherapy addresses the task of controlling concomitant anxiety-depressive syndromes and impulsivity. However, it must be approached with utmost caution, considering that sedatives reduce motivation for self-improvement; furthermore, these patients are a high-risk group for developing substance abuse. Lithium has proven effective in correcting episodes of aggressive behavior.

Emotionally unstable personality disorder

This group includes two subtypes—impulsive and borderline. They differ fundamentally from one another. What they have in common is perhaps the frequent antisocial direction of their behavior. The impulsive subtype was previously encountered in psychiatric literature under the names "epileptoid", which indicated the similarity of their behavior to that of patients with Epilepsy (outbursts of aggression at the slightest provocation), and "explosive" (from explosion), which pointed to their most characteristic behavioral pattern—brutal conflict. Some authors distinguished between epileptoid and explosive psychopaths, arguing that the latter, unlike the former, easily "cool down" and are not inclined to harbor malice. Their unification into a single group is due to the fact that in real life it is extremely difficult to separate the motivational component of the personality either in the conflict itself or after its completion. Therefore, on what basis can the subtypes of emotionally unstable personality disorder be diagnosed?

Impulsive subtype

The clinical diagnostic criteria for this disorder are as follows.

For diagnosis, the individual's condition must meet at least three of the following traits or behavioral patterns, among which the second must necessarily be included:

— a tendency to act unexpectedly without consideration of the consequences;

— !!! a tendency to quarrels and conflicts with others, especially when impulsive actions are thwarted or when their behavior is negatively perceived by those around them;

— a propensity for outbursts of violence or rage, with an inability to control explosive behavior (this often underlies the commission of sexual aggression);

— difficulty in maintaining any course of action that is not rewarded by immediate gratification;

— labile and unpredictable mood.

Treatment is comprehensive. Lithium and carbamazepine are the medications most commonly prescribed. Group and family psychotherapy aimed at developing adaptive coping patterns in conflict situations may also be utilized.

Borderline subtype

The clinical diagnostic criteria for this disorder are as follows.

For a diagnosis to be established, the individual's personality must meet at least three criteria formulated for the impulsive subtype, alongside at least two of the following traits or behavioral patterns:

— disturbances and uncertainty regarding self-image, personal goals, and internal preferences;

— a tendency to form intense yet unstable interpersonal relationships, frequently resulting in emotional crises;

— frantic efforts to avoid real or imagined abandonment and loneliness;

— recurrent self-destructive behavior, suicidal threats, or self-harm;

— a chronic feeling of inner emptiness.

The diagnostic Specificity of this disorder has already been mentioned: The behavior of “borderline” personalities (derived from “borderline”) largely resembles that of schizophrenia patients. Previously (prior to the Introduction of the 10th revision Classification), such cases were diagnosed as simple-type schizophrenia (its psychopathy-like variant), which further hindered the social adaptation of these individuals. Nevertheless, a fundamental distinction exists between a borderline personality and a schizophrenia patient (simple type or deficit state): the latter are characterized by autism and the psychological incomprehensibility of their motives, which is not true of borderline personalities. American psychiatrists distinguish yet another diagnostic Structure, intermediate between personality disorders and schizophrenia, known as schizotypal personality. However, discussing it goes beyond The Scope of this book.

Treatment for borderline personality disorder typically requires prolonged hospitalization combined with intensive individual and group psychotherapy. The primary therapeutic goal is to modify those primitive psychological defense mechanisms that cause an unrealistic perception of oneself and the environment.

Histrionic personality disorder

Due to its overt and flamboyant nature, this disorder rarely presents any diagnostic difficulties. Problems arise when the clinician attempts to “integrate” a histrionic personality into social life. The diagnostic criteria for this disorder are as follows.

Clinical diagnostic criteria include: egocentrism, demonstrativeness, vividness and shallowness of emotional reactions, deceitfulness, fantasizing, superficial thinking, stereotyped behavioral patterns detached from situational context, a constant need for support and approval, attempts to inappropriately display sexual charm in appearance or behavior, an intrinsic need to be physically attractive, feelings of discomfort in situations where the individual is not the center of attention, an inability to tolerate frustration or delayed gratification, extreme impressibility coupled with a paucity of speech details, motor disorders (hyperkinesia, tremor, paresis, paralysis, astasia-abasia-type gait disorders), sensory disturbances manifesting as sensitivity disorders (anesthesia, hypo- and hyperesthesia, algia, histrionic deafness, blindness), and autonomic dysfunctions (throat spasms, choking attacks, constipation, shortness of breath, etc.).

American psychiatry also identifies the so-called narcissistic personality disorder, which essentially represents a “grotesque,” specialized manifestation of histrionic disorder. Modern society is accumulating an increasing number of “narcissists.” This may be linked to the fact that society increasingly integrates the individual while leveling their distinct individuality. Consequently, the intensification of narcissistic traits (conviction of one's exclusivity and appeal to others, an a priori sense of entitlement to special privileges, etc.) serves as a specific psychological defense mechanism against the necessity of being a “cog in the wheel” within a complex, algorithmized society. This is most acutely manifested during adolescence, when an individual makes their first attempts to assert themselves as an autonomous person.

Treatment for histrionic individuals, much like narcissists, is exceptionally challenging because they cherish themselves just as they are, while their capacity for “mimicry” and play-acting prevents an objective assessment of immediate psychotherapy outcomes and makes it difficult to determine when therapy can be safely concluded to allow the individual to self-actualize in a socially constructive direction.

When discussing personality disorders in adults, certain aspects of forensic psychiatric evaluation must be addressed, as this particular group of patients frequently serves as its primary “supplier”: these individuals are often the perpetrators or victims of unlawful acts. Forensic psychiatric evaluations are conducted on an outpatient or inpatient basis (in exceptional cases, in absentia or even posthumously) by a commission of three experienced psychiatrists (occasionally, a single psychiatrist may be summoned directly to the courtroom during proceedings when doubts arise regarding the mental state of a defendant or witness, to prepare a forensic psychiatric assessment report) to determine sanity or insanity (as well as legal capacity or incapacity) of the suspect, accused, witness, or victim. Sanity, from a medical evaluation standpoint, encompasses both a cognitive aspect (the individual's ability to understand The Significance of their actions and consequences) and a volitional aspect (The ability to control one's actions). The mere presence of a mental disorder does not automatically determine a state of insanity. The majority of individuals we consider to have personality disorders (referred to under the older classification as psychopathic personalities) are deemed sane by the court, as they retain the capacity to understand the significance of their actions, even though governing them can prove quite difficult.

The next three disorders can be classified as Disorders of the “inhibited circle,” since the conflict involved is internal rather than external.

Anankastic (obsessive-compulsive) personality disorder

Individuals with this disorder are not prone to violating social norms, yet due to persistent self-doubt and indecisiveness regarding their decisions, they struggle to adapt to these norms effectively.

Clinical diagnostic criteria for this disorder:

— an excessive tendency to doubt;

— perfectionism (namely, the compulsion to execute everything to an exceptionally high standard of quality, regardless of the fact that certain tasks are temporary or ancillary in nature and do not require meticulous execution; conversely, when faced with tasks that genuinely demand higher quality but must be compromised due to time constraints imposed by more pressing, often unforeseen matters, anankastic individuals find the inability to achieve perfection an insurmountable challenge);

— excessive conscientiousness, scrupulosity, and disproportionate preoccupation with productivity to the detriment of work enjoyment and interpersonal relationships (a criterion that essentially expands upon the previous one);

— heightened pedantry and adherence to social conventions;

— unjustified, rigid demands that others conform to their exact methods, or an unreasonable reluctance to allow others to do things, even subordinates;

— recurrent, persistent thoughts and impulses throughout life that can assume the character of obsessions and rituals.

This disorder is typically characterized by the presence of certain traits already in early childhood, whereas the onset of the full disorder occurs in adolescence or even adulthood.

To correct indecisiveness and obsessions that significantly impair the social adaptation of anankastic individuals, certain antidepressants are occasionally prescribed.

Anxious Personality Disorder

These individuals live in a state of constant tension and apprehension, unable to simply enjoy life because they are forever anticipating misfortunes or troubles for which there is currently no objective basis.

Clinical diagnostic criteria for this disorder:

— hypersensitivity to rejection or inattention by other people;

— persistent and heavy anticipatory anxiety combined with a pervasive sense of tension;

— beliefs of social incompetence, personal unattractiveness, and inferiority relative to others;

— excessive preoccupation with being criticized or rejected in social situations;

— reluctance to enter into interpersonal relationships unless guaranteed to be liked;

— restriction of lifestyle due to a need for physical security;

— avoidance of social or occupational activities involving significant interpersonal contact out of fear of criticism, disapproval, or rejection;

— absence of close friends, with the exception of close relatives, and avoidance of forming deep, trusting relationships with others;

— reticence in social situations driven by the fear of saying something inappropriate or foolish, or by an inability to answer questions;

— fear of being ridiculed, blushing, crying, or showing outward signs of anxiety in front of others;

— exaggeration of potential difficulties, physical dangers, or risks when performing simple daily tasks that go beyond familiar routines.

As with the previous disorder, early childhood traits are typically present, while the clinical onset is observed in adolescence or even adulthood. Short courses of anxiolytic (anti-anxiety) medications are recommended for treatment, though psychotherapy and behavioral therapy remain the cornerstone of management, as with other personality disorders.

Dependent Personality Disorder

Dependent personality disorder is characterized by a subordinate pattern of behavior where individuals surrender their own needs to those of others, forcing the latter to assume responsibility for major life decisions. This is accompanied by a lack of self-confidence and considerable discomfort when left alone for more than brief periods. Treatment of these individuals is complicated by their tendency to shift the responsibility for therapeutic outcomes onto the psychotherapist while doing little themselves to achieve compensation. Their relatives also frequently remain dissatisfied with therapy, as dependent individuals tend to manipulate them by complaining that the doctor is incapable of solving their problems.

Given the profound impact that psychotraumatic circumstances have on our daily lives, alongside societal evaluation of our personality and our readiness to be part of its vanguard, the new classification introduces two novel categories of disorders absent in previous taxonomies: enduring personality changes after catastrophic experience and enduring personality changes after psychiatric illness.

Enduring Personality Change After Catastrophic Experience

The personality change must be chronic and manifest through rigid (recall that rigidity refers to an individual's inability to rapidly modify behavioral patterns when external circumstances change) and maladaptive features that lead to impairments in interpersonal, social, and occupational functioning. As a rule, this personality shift must be corroborated by data from objective sources. Diagnostic criteria are based on traits that were entirely absent in the individual prior to a specific traumatic period in their life:

— a hostile and distrustful attitude toward the world;

— social detachment;

— feelings of emptiness and hopelessness;

— a chronic sense of anxiety or constant threat; living "on the edge";

— estrangement.

Treatment of this personality disorder requires a long-term, committed, and empathetic therapeutic relationship between the psychotherapist and the patient. Various techniques can be employed, such as psychosynthesis, which involves reorganizing the personality around a new core, or a positivist approach that helps the individual conceptualize The Essence of their internal conflict and reshape their attitude toward it. However, the most crucial requirement is that this work be tailored to an individual "script" and take into account premorbid (i.e., pre-existing) personality traits.

Enduring Personality Changes After Psychiatric Illness

In this context, we are not referring to a specific period in the course of a mental illness (such as a residual defect state in schizophrenia), but rather to personality changes following recovery from a psychiatric disorder.

Clinical diagnostic criteria for this disorder include:

— excessive dependency and a demanding, consumer-like attitude toward others;

— a conviction of being permanently altered and stigmatized As a result of the past illness, leading to an inability to form and maintain close, trusting personal relationships, and resulting in social isolation;

— passivity, diminished interest in life, and abandonment of former hobbies and pursuits;

— persistent complaining about illness, which may coexist with hypochondriacal claims and sick-role behavior;

— dysphoric and labile mood, not attributable to a current mental disorder or a preceding psychiatric illness with residual affective symptoms;

— significant impairment in social and occupational functioning compared to the premorbid level.

We have examined the main forms of personality disorders in adults. Let us reiterate that the primary diagnostic criterion for this disorder is a persistent and pervasive maladaptation in social life. Familiarity with this section is essential for general practitioners, as such individuals will seek various forms of medical care. The delivery of this care and communication with these patients must take their behavioral patterns into account.

The diagnostic criteria for adult personality and behavior disorders primarily concern the emotional and volitional spheres. However, it is difficult to imagine that such profound personality deformation would leave cognitive functioning unaffected, even though formal intellectual prerequisites may remain "intact" and even genetically higher than the population average.

Regarding the treatment of these disorders, we must emphasize that, unfortunately, even today—despite the tremendous advances in psychopharmacology—it fails to fully meet the needs of psychiatry and humanity as a whole. These individuals live among us, and due to the maladaptive or even antisocial nature of their behavior, they frequently become sources of conflict, criminal acts, and other issues. Priority in treatment is given to behavioral therapy and various psychotherapeutic interventions, while pharmacological behavior correctors are recommended only in limited cases. Social programs aimed at compensating for personality and behavior disorders, as well as society's overall attitude toward those affected, are of great importance. Ultimately, harsh punitive measures, as human history has demonstrated, are incapable of resolving this complex problem, even temporarily.

Disorders of Psychological Development and Behavior Characteristic of Childhood and Adolescence

Among the psychological and behavioral disorders characteristic of childhood and adolescence, we will briefly review childhood autism, Rett and Asperger syndromes, and so-called hyperkinetic disorders.

Childhood autism manifests before the age of 3, occurring 3 to 4 times more frequently in boys than in girls. The child is striking for a lack of reaction to the emotions of others and an inability to adapt behavior to signals from their immediate social environment. The absence of emotional reciprocity with parents hinders the child's social integration. The second characteristic feature of the disorder is the child's inability to use language skills socially.

Asperger syndrome is closely related to childhood autism, but it lacks the general delay in language and cognitive development. Characteristic features include stereotyped interests and activities. The disorder persists into adolescence and even adulthood.

Rett syndrome occurs exclusively in girls and manifests between the 7th and 24th months of life; following a period of normal development, the child loses purposeful hand skills, accompanied by breathing irregularities (hyperventilation) and deceleration of HEAD growth. Later, stereotypic hand movements emerge. Development is delayed, but social interests are initially preserved. In middle childhood, There is a tendency toward truncal ataxia and apraxia, accompanied by kyphoscoliosis. Rett syndrome leads to severe mental disability in the child.

Hyperkinetic disorders are characterized by an early onset and a combination of excessively active behavior—which is resistant to external redirection—along with a lack of persistence and an inability to sustain attention when completing tasks. The core diagnostic features are attentional deficit and hyperactivity, which manifest across most situations.

Concepts of Military-Psychiatric Expertise

The objective of military-psychiatric expertise is to determine whether an individual suffering from a mental or behavioral disorder is fit to fulfill their civic duty of defending the Fatherland, specifically regarding compulsory military service.

Let us consider THE PRINCIPLE OF military psychiatric examination using the disorders discussed in this lecture as an example. Of course, the regulatory documents governing military psychiatric examinations will change depending on the state’s defense doctrine (such as the transition to a professional army), but the underlying principle will remain unchanged. An individual of military age who exhibits certain signs of a mental or behavioral disorder is deemed either fit, fit for limited service (i.e., eligible for non-combat units, but only during wartime), or unfit for military service. Crucially, the determining factor is not the specific diagnosis, but rather the severity of the disorder (mild, moderate, severe) and its reversibility (whether it resolves completely with treatment, is prone to relapse or decompensation, or is persistent and leads to social maladjustment). If a child suffers from childhood autism or Asperger syndrome, they will most likely be found unfit for active-duty service or admission to a higher military educational institution. Even with a favorable course of the disorder, the stressful conditions of military service are highly likely to trigger an adaptation breakdown followed by an exacerbation of symptoms.

However, individuals with adult personality and behavioral disorders whose symptoms are assessed by a psychiatric commission as mild (or occasionally moderate) may perform wartime military service, provided it does not require effective interaction with numerous other servicemen or adaptation to the challenging conditions of front-line combat units. For instance, during a critical period of wartime hostilities, individuals with schizoid personality disorder can perform various support tasks in rear-unit positions (such as repair units, communications, or field postal service), while those with hysterical personality traits may be drafted during wartime to serve in mobile mess units, army supply depots, or military clubs. It must be emphasized that in every individual case, fitness for military service is determined on a case-by-case basis by a medical board.