Psychiatry - O. K. Napreenko 2001

Clinical Psychiatry
Personality Disorders. Accentuations

DEFINITION OF TERMS

Psychopathies (in the International Classification of Diseases, the standard term is "personality disorders") are persistent and pronounced personality anomalies characterized by disharmony of character that lead to behavioral impairments and difficulties in interpersonal relationships, thereby hindering the individual's social adaptation. Due to this pathological character Structure, such individuals either suffer themselves or torment those around them. Psychopathies manifest as emotional and volitional disorders in the presence of intact intelligence. The initial signs of psychopathy development are observable as early as childhood, while its formation concludes in adolescence (ages 18–20), which is when personality maturation is largely completed. Psychopathies are not inherently progressive, yet they exhibit dynamic changes throughout life.

The boundary between a personality disorder and a healthy psyche is not always distinct, and transitional states lie along this continuum (V. M. Bekhterev, 1866), having received various designations. The most notable among these are the accentuated personality (K. Leonhard, 1968) and character accentuation (A. E. Lichko, 1977).

Personality accentuations represent an extreme variant of normal development in which individual character traits are overly pronounced, resulting in a selective vulnerability to certain types of psychogenic influences alongside good or even heightened resistance to others. Character accentuations (accentuated personalities) are subdivided into specific variants, most of which correspond to known forms of psychopathy (unstable, histrionic, explosive), while others differ from them (e.g., conformist) or form mixed (intermediate) types.

Personality accentuations are inherent to healthy individuals and do not constitute a clinical Diagnosis in themselves. However, they can serve as a premorbid Background, a soil, or a trigger for The Development of psychogenias (acute affective, neurotic, and psychopathic reactions, neuroses, psychopathies, reactive psychoses), as well as psychosomatic disorders. In this context, psychogenias arise exclusively under conditions of psychological trauma or severe situations where The Significance of the psychogenic factor targets a specific "weak link" corresponding to a particular personality type.

Epidemiological Data

Due to discrepancies in understanding The Essence and diagnostic criteria of psychopathies, data regarding the frequency of personality anomalies in populations vary considerably: ranging from 0.07–3.1% to 15% in the general population, and 4.3–10.4% among patients hospitalized in various psychiatric facilities. Psychopathies are diagnosed significantly more often in men than in women. Moreover, while this ratio is 2:1 in adults, it reaches 3:1 among adolescents. This may be partly because, in countries with mandatory military service, psychopathy in young men is frequently diagnosed during military conscription. Excitable and hysterical psychopathies are observed most frequently. Nonetheless, the majority of psychopathic individuals remain outside the purview of psychiatrists; consequently, available data primarily reflect the prevalence of the most severe personality anomalies, registered cases, or patients hospitalized in psychiatric clinics.

Etiology AND Pathogenesis

The genesis of psychopathies combines innate and acquired, biological and social factors. However, because THE CONTRIBUTION OF these factors to The formation of a pathological character may vary depending on dominant causes, psychopathies are divided into several groups.

Constitutional (genuine, innate, nuclear) psychopathies are determined by heredity and manifest in children aged 4–6 years even under favorable living conditions. Similar pathological character traits can often be traced in parents or other Blood relatives, although a specific pattern of inheritance has not been established.

Psychopathic or pathocharacterological pathology (borderline, acquired psychopathies, pathocharacterological formations) is the result of prolonged psychogenic impact, improper upbringing, or an unfavorable social environment, especially when occurring during adolescence (the period of character formation) in the presence of a fertile ground, such as character accentuation. It is noteworthy that not just any prolonged adverse socio-psychological influence causes this, but specifically one that targets the "point of least resistance" associated with a particular type of accentuation. Only exceptionally harsh conditions are capable of shaping a pathological character against any background (e.g., upbringing from early childhood through adolescence in a strict-regime closed institution).

Alongside disorders of situational and psychogenic origin, the group of acquired psychopathies also includes so-called organic psychopathies.

Organic psychopathies are the consequence of organic brain damage resulting from prenatal, natal, and early postnatal (the first 2–3 years of life) pathogenic impacts on the developing brain. Harmful factors may include injuries, severe gestosis during Pregnancy, fetal birth trauma, intrauterine and early childhood infections, neuroinfections, avitaminosis, and prolonged debilitating somatic illnesses from the first years of life. Examinations reveal residual neurological microsymptomatology: Asymmetry of facial innervation, minor oculomotor disorders, uneven tendon and Skin Reflexes, and diencephalic disorders. Skull radiographs show ossification anomalies and signs of elevated intracranial pressure, while EEGs demonstrate pronounced diffuse changes. Psychological testing reveals attentional impairments, mental exhaustion, and a tendency toward excessive concretization.

The Significance of the pathobiological radical is greatest in organic psychopathies. However, The Role of the biological substrate and Nervous system defectiveness in the genesis of other psychopathy groups is likewise evidenced by micro-organic signs, electroencephalographic data, functional peculiarities of the brain's biochemical (catecholaminergic) systems, and neuro-autoimmune indicators. All of this points to The Unity of pathogenetic mechanisms underlying psychopathies that develop against the background of an interaction between congenital or early acquired biological inferiority of the Central nervous system and adverse societal influences.

Clinical Picture and Course of Personality Disorders

The polymorphism of clinical manifestations in personality disorders and the lack of uniform principles for their systematization account for the existence of various classifications, each of which is not without certain limitations. Nevertheless, all of them—grounded in THE PRINCIPLE OF identifying the primary emotional and volitional disorders specific to a given anomalous personality structure—point to the clinical reality of paranoid, affective, schizoid, excitable, psychasthenic, hysterical, asthenic, emotionally blunted, and unstable forms. This aligns with the International Classification of Personality Disorders. It should be borne in mind that a "pure" clinical picture of a specific type of psychopathy is practically nonexistent; each type frequently incorporates traits of another psychopathic form. For instance, hysterical psychopathy often exhibits Characteristic Features of excitable psychopathy, and vice versa. In such cases, the psychopathy type is diagnosed based on the predominant traits.

The paranoid type is characterized by a "biological readiness" and a propensity for The Emergence of affectively emphasized ("overvalued") ideas of various contents (relations, jealousy, hypochondriacal inventiveness) linked to a real life event (e.g., an instance of unjustified negative attitudes toward the individual, ineffective medical Treatment, or suspected spousal infidelity).

Over time, individuals obsessed with such an idea tend to evaluate reality unilaterally, selectively choosing and interpreting various events to corroborate their viewpoint. Thus, the suspicion receives "validation" and becomes increasingly entrenched and systematized, acquiring a delusional coloring. It is impossible to dissuade such a person of the fallacy of their beliefs: any counterargument causes irritation and is interpreted as a manifestation of disrespect or enemy machinations. Interpersonal relationships are disrupted, and conflicts arise within the family or working collective. Emotionally charged thoughts dictate behavior and actions; for instance, such individuals may stubbornly and relentlessly persecute their "enemies" ("persecuted persecutors") or subordinate all their interests to a single cause or idea (fanatics). From childhood, key traits of paranoid personalities include: inflated self-esteem and a tendency toward leadership; egocentrism; hypersensitivity of the ego; constant resistance and opposition to the entire world; stubbornness and directness; one-sided interests and low psychic flexibility; heightened touchiness; affective tension; distrustfulness; suspiciousness; and vindictiveness.

The affective type is subdivided into hypothymic, hypertymic, cycloid, and emotionally labile psychopathies. Hypothymic psychopaths are pessimistic regarding reality, the past, and the future, perceiving only the dark aspects of life in everything. Under METABOLISM/18.html">The Influence of adversity or illness, they easily develop subdepressive and depressive states, occasionally accompanied by suicidal tendencies. Conversely, hypertymic psychopaths exhibit a persistently elevated mood. They are optimistic, ambitious, self-confident, unceremonious, energetic, active, tireless, and talkative, yet boastful with unstable interests and superficial judgments. The cycloid type is characterized by periodic shifts from a somewhat elevated mood to a depressed one, accompanied by corresponding fluctuations in productive activity. The emotionally labile (reactively labile) type features frequent, sudden mood shifts triggered by even minor events. They react poorly to psychological trauma (for example, the death of loved ones may precipitate a reactive psychosis). Joyfulness can instantly turn to despair. Such individuals are extremely vulnerable, highly suggestible, lack stable behavioral motives or interests, and possess deficient willpower (displaying passive subservience).

The schizoid type encompasses a diverse range of pathological traits in anomalous personalities, the common denominator of which is primarily pathological withdrawal, a lack of need for social interaction, detachment from real life, and autism (autistic type). Even in childhood, these patients prefer solitude and avoid participating in group games. Their interests do not correspond to their age; for instance, they may take an early interest in complex philosophical or political problems or read adult literature and periodicals. They are prone to fantasizing and deeply absorbed in an internal world (introspection) that remains permanently closed and thus incomprehensible to others. Most commonly, selective sociability is observed, with contacts limited to a narrow circle of relatives or focused on one or two close friends. Free time is dedicated to reading, fishing, nature contemplation, or other "autistic" pursuits.

Characteristic Features of the schizoid state also include disharmony and the paradoxical nature of mental Life as a whole. In clothing, they display accentuated elegance or, conversely, deliberate sloppiness. Due to underdeveloped motor skills, their movements lack fluidity and appear bizarre, and their facial expressions are impoverished and standardized. Their gait may be caricatured. They are frequently labeled as eccentrics or originals. Their hobbies tend to be one-sided and obscure, though not disconnected from reality, often linked to the activities of the people they interact with. At the same time, they demonstrate remarkable persistence in achieving goals of personal significance. They remain entirely indifferent to family interests and job duties, and may be unmanageable at work. Prone to non-conformism, they dislike doing things "like everyone else." Difficulties in understanding and assimilating generally accepted behavioral norms manifest as eccentric actions. Emotional disharmony transforms into an inability to experience pleasure (anhedonia) and empathize with others. Establishing informal emotional contacts is challenging, and they exhibit little interest in sexual life. Depending on The Nature of their emotional response to the environment, a distinction is made between sensitive schizoids—characterized by a hypersthenic component, excessive sensitivity, vulnerability, and suspiciousness—and expansive schizoids, featuring elements of emotional "anesthesia" (indifference toward people, manifestations of cruelty, outbursts of anger, and impulsive actions).

The excitable (epileptoid) type is characterized by exceptionally strong emotional excitability and explosiveness. Even in childhood, such patients are intolerant of any restrictions or prohibitions, which triggers outbursts of anger and aggressive protest. A propensity for affective reactions makes them extremely "difficult" within the family, at school, and in later life. Emotional explosions occur at the slightest provocation, yet anger easily gives way to tears; swearing and throwing objects turn into groaning, and aggression toward others shifts to self-harm or suicide attempts (both demonstrative blackmail and genuine attempts). Unrestrained and easily angered by the slightest remark or opposition, they overreact to any stress. Typically, following such an outburst of anger, they regret their behavior, only to repeat it later. Periodically and without apparent cause, a gloomy-malicious mood—dysphoria—arises (lasting from several hours to several days), during which the patient seeks someone to vent their frustration upon. Such individuals are egocentric, overly demanding of others, tidy, pedantic, meticulous, and possess viscous thinking. They are vindictive, ingratiating, and cruel (resembling the pattern seen in Epilepsy). Occasionally, they exhibit drive disorders, most commonly a propensity for sadomasochistic perversions; for instance, from childhood, they may take pleasure in tormenting and killing animals, bullying the weak and defenseless, or inflicting pain upon themselves via cuts or cigarette Burns. Excitable psychopaths tolerate alcohol poorly, and intoxication may be accompanied by dysphoria. In fights, they become vicious and inflict severe bodily injuries.

The psychasthenic type is distinguished by a lack of internal self-confidence in the correctness of one's actions, feelings, and thoughts, accompanied by a sense of inferiority, anxiety, doubt, and indecision. This fosters the development of various obsessions (obsessive fears, thoughts, apprehensions, desires, and urges). Given the dominance of these traits within the personality structure, the psychasthenic character is also termed anxious-suspicious. The traditional designation for this psychopathy type According to the International Classification is "anankastic" personality disorder, which denotes the predominance of obsessions. Already in childhood and school age, excessive shyness, self-doubt, heightened vulnerability, and timidity become noticeable. To ward off anticipated failures and misfortunes, such individuals begin to believe in good and bad omens, incantations, and rituals. For instance, to avoid receiving a negative grade, they may wear specific clothing, ride transport with even-numbered tickets, or draw tickets exclusively with their left hand. Psychasthenic traits intensify when these individuals begin living independently. They find it extremely difficult to make decisions even on trivial matters, constantly analyze their actions, repeatedly check completed tasks, and exhibit excessive caution regarding potential dangers or adverse events. Persistent anxiety and the anticipation of complications, misfortunes, or unpleasantness prevent such individuals from experiencing pleasure. A unique defense mechanism and compensation for constant apprehension is found in over-conscientiousness, scrupulosity, and pedantry combined with rigidity, stubbornness, importunity, and high demands placed on others. All of this hinders adaptation to life and fosters the development of neurotic (obsessive) states under psychotraumatic circumstances.

The hysterical type of psychopathy is characterized by a constellation of traits such that the experiences of these individuals are termed demonstrative, and the individuals themselves are referred to as mythomaniacs or pseudologists. They feature high emotionality and exaggerated emotional expression characterized by very turbulent yet superficial and short-lived reactions. Emotional, affective, and distorted logic leads to a reflection of the environment through a "crooked mirror." Heightened suggestibility is combined with childish stubbornness and capiousness. Such individuals are egocentric, self-absorbed, and possess a morbid self-love and an inflated opinion of themselves, forgiving themselves everything while disregarding the interests of others. They lay claim to far more than their abilities and opportunities warrant. However, among these pathological traits, the most prominent is the drive to draw attention to themselves and their actions. Raised as the "family idol," they constantly crave admiration, distinction, recognition, and high praise. This explains the brightness and extravagance of their attire, as well as the non-standard nature of their gestures and facial expressions. Because they strive to appear more significant and better than they truly are, their behavior is unnatural, theatrical, and demonstrative, calculated for an outside spectator. Dissatisfied with their social standing, they readily substitute real situations with invented ones ("pseudologia phantastica"). They are deceitful, prone to self-aggrandizement, and inclined to manipulate (fabricate) facts to achieve their goals. In conflict situations, decompensations occur via "flight into illness," demonstrative suicides, or other hysterical reactions accompanied by arousal, paralysis, astasia-abasia, or aphonia. In severe cases, hysterical psychoses are accompanied by altered states of consciousness and pseudodementia.

The asthenic type, alongside the psychasthenic, is classified among the inhibitory circle of psychopathies. Their biological foundation is a low level of nervous Cell work capacity (weak type of Higher Nervous Activity) with a lowered "excitability threshold" regarding psychic and somatic stimuli. Such "constitutionally nervous" properties form the substrate for the development of asthenic symptom complexes—heightened irritability and pronounced exhaustion of mental processes ("irritable weakness"). Characteristic features of children and adolescents with this pathology include heightened vulnerability, easy hurtfulness, emotional instability (tearfulness), rapid fatigue, and a drive to avoid difficulties. The sensation of mental and physical weakness fosters timidity, shyness, and a sense of personal inferiority (lowered self-esteem). They are perpetually dissatisfied with themselves, adapt poorly to novelty, and react hypersensitively to the tactlessness of others ("oversensitive natures"). Circumstances that are normal for others (e.g., having to speak before an audience) can knock such an individual out of equilibrium for a prolonged period. Being self-conscious, these individuals deeply experience their own inadequacy, which keeps them in a state of constant internal tension. This manifests as sudden outbursts of irritation resembling "slip-up" reactions directed at innocent people. Decompensation occurs under increased workload or complex life circumstances, leading to the depletion of mental manifestations.

Individuals with emotionally blunt personalities (personality disorders featuring sociopathic or antisocial traits) are clinically closely linked to expansive schizoids (who are emotionally cold and cruel), excitable individuals (characterized by irritability, wrathfulness, spite, and emotional explosiveness), as well as unstable individuals (exhibiting negative behavioral patterns and delinquency). However, the core trait of emotionally blunt psychopaths that hinders their social adaptation is the underdevelopment of higher moral feelings. In the past, such mental deviations were classified as moral immaturity of the personality (moral oligophrenia). Such children and adolescents are callous, inconsiderate toward loved ones, use foul language, and begin to steal. They run away from home, are prone to vagrancy, and abuse alcohol and drugs. The primary character traits of these individuals also include a deficiency in higher emotions such as love, friendship, compassion for others, conscience, honor, shame, and the like. They do not repent, feel no guilt, and remain indifferent to praise as well as threats and contempt. They are incapable of learning from past experience, particularly from punishment. Their entire life is a continuous conflict with the law: theft, robbery, violence, and so on. Much like excitable individuals, they tolerate alcohol poorly and become even more aggressive when intoxicated.

The unstable type is characterized by underdeveloped volitional qualities, weakness of will combined with a heightened susceptibility to external influences. Such people are disorganized and lazy, lacking deep life goals. They live in the present moment. They fail to see tasks through to the end, especially when achieving a goal requires significant effort (for instance, due to idleness and slothfulness, despite good intellectual capabilities, they lag behind in their studies and fail to complete their education). They are convinced of the righteousness of their actions and are deceitful. They shift the blame onto others. They find solitude oppressive, love company, and thus seek out entertainment and adventure. With constant monitoring of their behavior, such individuals can sometimes achieve partial compensation and manage to adapt to life somehow. More often, however, they fall into antisocial company, abuse alcohol, and may become accomplices in criminal offenses.

The dynamics of psychopathies refer to specific temporal changes within the relatively constant states of anomalous personalities that emerge over the course of a lifetime due to increased sensitivity to various external factors (psychogenic, social, or somatogenic) and biological transformations in the body (age-related crises, Menstrual cycle, pregnancy, childbirth, etc.).

Specific manifestations of psychopathy dynamics include: psychopathic reactions, psychopathic states (compensation, decompensation, attacks, phases), and pathological development.

Psychopathic (pathsetCharacterological) reactions are short-term personality changes characterized by a significant intensification of character traits and quantitative changes in them. They occur immediately after the appearance of an immediate cause (psychogenic or somatogenic), representing an altered form of response to a specific external stimulus (psychogenic and somatogenic psychopathic reactions). Typical features include an altered form of response, inadequacy of the stimulus in both strength and content, as well as rapid onset and regression with the restoration of the previous state. Clinically, the form of response may or may not correspond to the specific type of psychopathy. For example, a psychopathic reaction of an explosive nature, marked by extreme anger and aggressiveness over a minor provocation, may occur in excitable and hysterical psychopaths.

Psychopathic reactions differ from neurotic ones by the absence of a sense of illness, and from psychotic ones (affective-Shock reactions, pathological affect) by the absence of gross cognitive impairments (disturbances of consciousness, hallucinations, delusional ideas, etc.).

Compensations are a temporary mitigation of character traits that ensures the individual's adaptation to their microenvironment (family or work). This is usually driven by a favorable environment (for example, a solitary lifestyle with the opportunity to fully dedicate oneself to a favorite activity or interests in schizoid psychopathy). Less commonly, compensation occurs through the active development of psychological defense mechanisms or behavioral patterns that contrast with psychopathic traits, thereby masking them. However, under severe conditions, these mechanisms prove insufficient, and the true psychopathic features resurface. Frequently, such defense mechanisms in the form of hypercompensation (e.g., rudeness, insolence, or uncompromising behavior in asthenic psychopathy) are themselves manifestations of impaired environmental adaptation.

De-psychopathization is a persistent smoothing out of psychopathic character traits accompanied by long-term compensation. It occurs under favorable conditions, particularly when family relationships are harmonious. Patients tolerate routine life difficulties and everyday stress satisfactorily. The character type does not change, but this does not hinder social adaptation.

Decompensation is a period in the dynamics of psychopathies characterized by a prolonged exacerbation of psychopathic traits, typically manifested through behavioral disorders and social maladaptation. It most frequently develops under the Influence of Environmental factors that are unfavorable specifically to that type of psychopathy—factors that would have no impact under other variants or in normal conditions. For instance, in psychasthenia, decompensation easily occurs in the event of workplace conflicts, whereas in excitable psychopathy, patients are primarily intolerant within the family Setting. Biological factors drive decompensation during periods of developmental crises—Puberty and menopause. During puberty, pathological character traits manifest more strongly in boys, whereas during the menopausal period, they are more prominent in women.

Psychopathic attacks are periodic, apparently causeless phases of sharp exacerbation of pathsetCharacterological traits, followed by a spontaneous return to the prior baseline state (for example, dysphoria in epileptoid psychopathy). The lack of a clear correlation between the clinical manifestations of attack-phases and the psychopathic makeup of the personality, as well as their restriction to specific types of psychopathy (cycloid, schizoid, and epileptoid circles), may point to a complex genesis involving a specific "endogenous radical." The clinical picture of these phases, dominated by Affective Disorders, may manifest through minor signs (attenuated phases), distinct psychopathic disorders with dysthymia, or prolonged (up to 2–3 years) depressive phases with a severe course. The latter are most frequently observed in the dynamics of affective psychopathy, dominated clinically by sluggishness, apathy, and a loss of interest. These must be differentiated from endogenous psychosis.

Pathological development is a specific type of psychopathic dynamics that reflects clinically diverse processes of characterological decompensation, manifested by a unilateral, persistent intensification of specific traits in an anomalous personality. It results from internal, constitutional causes (constitutional development) or may arise from unfavorable interactions with the external world (situational development). An example of constitutional development is the intensification of schizoid traits in schizoid psychopathy. Among situational pathological developmental variants, paranoid personality development holds the greatest significance; it can emerge in psychopathic as well as accentuated individuals across various groups (psychasthenics, asthenics, hypertimics, schizoids, excitable individuals, etc.). It arises during the period of social maturity (at ages 30–40), immediately following the onset of psychotraumatic circumstances, which may include unfavorable social conditions. Overvalued ideas appear and subsequently generalize, the capacity for self-criticism is lost, and behavior changes drastically (for example, the patient constantly complains about their "enemies" or searches for proof of spousal infidelity). Ideas of jealousy, persecution, litigiousness, and less frequently, grandiosity, reformism, or hypochondriasis are most commonly observed. Against a backdrop of conflict situations, overvalued ideas transform into delusions. As the psychotraumatic situation subsides or the somatic state improves, delusional symptoms gradually recede.

Diagnostic criteria and Differential diagnosis

The diagnostic criteria for psychopathy are three features established by P. B. Gannushkin and O. V. Kerbikov: 1) the totality of pathological character traits, which manifests everywhere and at all times (at home and at work, during leisure, in familiar conditions, and under emotional stress); 2) the stability of pathological character traits (persisting throughout life, although first noticed in childhood); and 3) social maladaptation, which is a direct consequence of the pathological character traits themselves rather than specific circumstances.

Unlike psychopathies, character accentuations typically develop during the period of character formation and disappear with age. They manifest only in specific situations because they are not accompanied by social maladaptation, or their course tends to be transient. Thus, character accentuations never exhibit all three mandatory features of psychopathy defined by P. B. Gannushkin and O. V. Kerbikov.

In cases of psychopathy, differential diagnosis is conducted primarily in two directions: distinguishing it from psychopathic (pathsetCharacterological) reactions, and from psychopath-like states characteristic of other mental illnesses. The distinction between transient, situationally induced reactions within the dynamics of psychopathies and character accentuations versus similar reactions in other mental and somatic disorders is determined based on the criteria of P. B. Gannushkin and O. V. Kerbikov.

When differentiating between psychopathy and neurosis, one must account for the patient's subjective sense of illness, accompanied by an active drive to rid themselves of pathological manifestations, as well as the presence of a somatovegetative component in the clinical picture of neurosis (headache, tachycardia, blood pressure fluctuations, gastrointestinal disorders, etc.). At the same time, one should not overlook the possibility of neurotic pathsetCharacterological development, which indicates the close affinity of these two borderline neuropsychiatric disorders.

The need frequently arises for differential diagnosis between psychopathies, certain forms of sluggishly progressive Schizophrenia, and manic-depressive psychosis. Evidence pointing toward the process-based nature of schizophrenia includes the presence of neurosis-like and other disorders not driven by psychogenic influences, the monotony of obsessive manifestations, a tendency toward the systematization of obsessions and the formation of rituals, and the reduction of the vegetative component.

Paranoid states within the framework of psychopathy dynamics differ from schizophrenia in that a close connection can be traced between the content of overvalued ideas and real events, along with a gradual reduction of symptoms upon the removal of psychotraumatic situations or the improvement of the somatic state.

The greatest difficulties arise when one must differentiate between psychopathy and schizophrenia with a psychopath-like course. Psychopathy is characterized by the emergence of pathsetCharacterological features in childhood that intensify during puberty. Schizophrenia, conversely, is marked by a "process shift," wherein an individual with a normal premorbid baseline suddenly develops psychopath-like states with drastic behavioral changes during adolescence. Hatred toward loved ones, cruelty, malice, aggressiveness, emotional flattening, and "wild" hobbies appear abruptly and without cause. Cognitive activity is disrupted, and—most importantly—thinking is impaired alongside a progressive increase in negative symptoms.

When differentiating from psychopath-like disorders resulting from organic brain damage (following TRAUMATIC BRAIN INJURIES, neuroinfections, and poisonings of alcoholic or substance-abuse origin), primary attention is paid to anamnestic data regarding trauma or illness, the presence of neurological symptoms, and signs of psycho-organic syndrome development. For instance, in the Clinical presentation of chronic alcoholism, against a background of asthenia and continued alcohol consumption, encephalopathy develops—characterized by psycho-organic disorders with explosive reactions, excitable-type psychic changes, aggression, and bouts of dysphoria.

Treatment, rehabilitation, and Prevention

Treatment for psychopathies aims to compensate for personality anomalies and correct pathsetCharacterological features in order to achieve optimal adaptation of the patient to their environment. This approach takes into account the clinical CHARACTERISTICS OF THE psychopathy, combining the effects of psychopharmacotherapy, psychotherapy, and social rehabilitation measures.

The question of treatment in psychopathies is closely tied to the dynamic Changes in the personality. In a state of compensation with preserved adaptation, there is no need for specialized treatment; however, in cases of psychopathic reactions, decompensation, attack-phases, and pathological developmental variants, psychiatric assistance is indispensable. Indications for emergency hospitalization in a psychiatric facility without the patient's consent include psychoses developing at the peak of decompensation (twilight states in the hysterical type, severe dysphoria and pathological affects in the explosive type, delusional psychoses in paranoid psychopathy), as patients become dangerous to others (due to aggressive tendencies) or to themselves (suicidal intent, self-harm).

Psychopharmacotherapy is administered depending on the leading psychopathological syndrome.

In cases of psychopathic agitation, when a patient requires emergency psychiatric care, rapid administration of psychotropic medications with sedative effects is employed—specifically, aminazine or tizercin (2–3 ml of a 2.5% solution) combined with 3 ml of a 2% diphenhydramine solution administered intramuscularly, clopixol (2 ml — 20 mg), seduxen (40–60 mg), neuleptil (up to 60 mg), phenazepam (5–6 mg), radedorm (10 mg), or tranxene (150–300 mg daily). Correctors (such as parkopan or cyclodol) are prescribed. For severe agitation and dysphoria rooted in organic brain deficiency, neuroleptic agents are combined with finlepsin (carbamazepine, tegretol) or chloracon.

During decompensations of paranoid psychopathy, antipsychotic medications are prescribed (haloperidol, trisedyl, zyprexa, risperidone, clopixol, fluanxol, orap, semap, solian, stelazine) in combination with correctors (parcopan, cyclodol) and sedating tranquilizers (phenazepam, radedorm, tranxene, sibazone, etc.).

Affective psychopathies with predominant hypothymic manifestations are treated with antidepressant medications (azafen, cipramil, prozac, zoloft, pyrazidol) and stimulants (trioxazine, rudotel, sydnophen, sydnocarb). Hyperthymic manifestations are alleviated with soothing agents (sibazone, phenazepam, neuleptil, tranxene, radedorm, ivazan), alongside carbamazepine, carbasan, and lithium carbonate. Similar psychopharmacological correction is applied in psychopathies with emotional lability.

In asthenic and psychasthenic psychopathies, drug therapy should be general tonic combined with psychopharmacological correction of asthenic and anxiety-suspicious traits through the administration of tranquilizers (trioxazine, tazepam, rudotel, meprobamate), psychostimulants (sydnophen, sydnocarb), and nootropics, which include pyriditol (encephabol), pantogam, and piracetam (nootropil).

Schizoid pathocharacterological decompensations are corrected using low doses of stelazine and frenolon combined with long-acting neuroleptic agents (moditen depot, clopixol depot, fluanxol depot, fluspirilene), englonyl, and sonapax.

Reduction of emotional responsiveness in histrionic personality disorder is achieved using tranquilizers (phenazepam, seduxen, radedorm, tranxene, ivazan, etc.) and neuroleptic agents (aminazine, neuleptil, zyprexa, risperidone, fluanxol).

The manifestations of characterological features and behavior in patients with excitable psychopathy are corrected through the long-term administration of neuleptil (20–60 mg per day), as well as other soothing neuroleptic agents (aminazine, tisercin, chlorprothixene, clopixol, fluanxol, combined with parcopan — zyprexa, solian, risperidone), and tranquilizers (phenazepam, tranxene, ivazan, radedorm, seduxen, etc.).

Given the significant impact of psychogenic factors on the dynamics of psychopathies, psychotherapy plays a crucial role in achieving compensation for characterological anomalies and normalizing interpersonal relationships. It should primarily be individual. The choice of Methods depends on the type and dynamics of the psychopathy. Patients with psychasthenic and paranoid types should be patiently convinced that their self-esteem is either overestimated or underestimated, that they need to change their demands on their environment, and they should be helped to sort out their doubts and suspicions, instill self-confidence, etc. In excitable and hysterical psychopathies, a directive-suggestive approach is used to counteract affective outbursts and neutralize negative manifestations of the patient's character, teaching them self-control and how to restrain their own emotions. Not only individual but also group psychotherapy, particularly family therapy, has a positive impact on pathocharacterological traits and behavior. In group psychotherapy, the mutual influence of patients from a specially selected group is of great importance (overcoming insecurity, anxiety-suspiciousness, etc.). The goal of family therapy, based on a correct understanding of character traits, is the normalization of intra-familial relationships, the search for compromises, and a proper assessment of each other's behavioral motives.

The rehabilitation of psychopathic personalities is primarily aimed at fostering an active life stance and stable work habits that ensure the possibility of social functioning. When choosing a profession and specialty, the patient's character traits should be taken into account. Work should facilitate the compensation of psychopathy rather than hinder adaptation. Important health-improving factors include environmental sanitation, isolation from individuals with antisocial tendencies, the formation of favorable family relationships, and good relations with others.

The prevention of psychopathies depends on living conditions, societal relations, maternal and child healthcare measures, and the prevention of pre- and postnatal central nervous system injuries. Above all, it is necessary to create an optimal psychological climate for the development of children and adolescents (family, kindergarten, school, etc.) and proper social conditions for the formation of a harmonious personality.

Prognosis

The prognosis in psychopathies depends on their clinical picture and the social environment. In cases of prolonged and almost continuous decompensations, despite improved living conditions, the social prognosis is unfavorable (a parasitic lifestyle, heavy drinking, drug use, and crimes lead to personality degradation). Psychopathies also carry a high risk of developing alcoholism, substance dependencies and addictions, criminal behavior, and suicide. If decompensations are caused by real psychological trauma and are short-lived, there is more hope for the possibility of depsycopathization overall. In nearly 15% of patients 12–15 years after the diagnosis of psychopathy, no characteristic pathology was observed, and in 25% of cases, psychopathic traits were significantly smoothed out, achieving satisfactory social adaptation. Thus, the prognosis in psychopathy depends on the features of its dynamics, which can manifest in three ways: with complete compensation, with partial compensation, or without improvement in condition.

Examination

Work capacity in psychopathies is generally preserved, with decompensations accompanied by its temporary disruption. Loss of work capacity is considered persistent (with a recommendation to select an adequate type of labor activity) in cases of group III disability in rare instances, due to prolonged complications (decompensations, pathological development).

The tasks assigned to forensic psychiatric examination are resolved individually, taking into account both the Specifics of the offense and the dynamics of the clinical manifestations of psychopathic disorders, as well as the level of social adaptation of the particular individual. In most cases, patients with personality disorders are deemed sane. Only psychopathic individuals who committed antisocial acts during severe decompensation with extreme distortion of emotionality, impairment of thinking and the motivational sphere, and complete loss of critical faculty may be declared insane.

Psychopathic individuals are exempt from active military service.

Review Questions

1. Definition of the concepts of "psychopathy" and "personality disorder". Epidemiology, etiopathogenesis.

2. Criteria for psychopathies, as defined by P. B. Gannushkin and O. V. Kerbikov.

3. Clinical presentation of psychopathies. Obligate and facultative signs.

4. Characteristics of Clinical forms of inhibited-type psychopathies.

5. Characteristics of clinical forms of excitable-type psychopathies.

6. Mixed-type (mosaic) personality disorders.

7. Dynamics of psychopathies. Psychopathic reactions, compensations and decompensations, pathological personality development.

8. Treatment, rehabilitation, expert evaluation, and prevention of psychopathies.

9. Definition and typology of personality accentuations, methods for their identification.