Psychiatry - H.T. Sonnyk 2003

Psychopathies (Personality Disorders)

Psychopathies (or “personality disorders” according to ICD-10) are persistent, pronounced personality anomalies (primarily affecting the emotional and volitional spheres while preserving intellect) that manifest as character disharmony and create challenges for an individual’s social adaptation.

Psychopathies are classified as non-progredient conditions, yet they exhibit a certain degree of dynamics throughout a person's life. A clear distinction must be drawn primarily between psychopathies and personality accentuations.

Personality accentuations represent an extreme variant of normal development&mdashan exaggerated expression of specific character traits that renders an individual selectively vulnerable only to certain psychogenic influences.

P. B. Gannushkin identified clear diagnostic criteria for psychopathies (known as Gannushkin's triad), which remain fully relevant today: the persistence of psychopathic manifestations, meaning the constancy of personality disorder traits with no tendency to "disappear" over time; their totality, implying that pathological character traits permeate the entire personality Structure; and social maladaptation, reflecting the difficulty&mdashand sometimes absolute impossibility&mdashof such an individual functioning within a given environment.

Historical Background.

As early as the first half of the 19th century, character anomalies were described in the works of J. Prichard (1853) as "moral insanity," E. Esquirol (1838) as "instinctive monomania," and U. Trelat (1846) as lucid insanity. A distinct direction in The Study of this pathology emerged following B. Morel's (1857) treatise on "physical, mental, and moral degeneration," which viewed any mental disorder as a manifestation of hereditary degeneration. The definitive Separation of this pathology from the amorphous concept of degenerative psychoses was achieved through the works of W. Griesinger (1866) and H. Maudsley (1868).

A major contribution to the clinical study of psychopathies was made by S. S. Korsakoff (1880), V. Kh. Kandinsky (1883), I. M. Balinsky (1884), and V. M. Bekhterev. In 1933, P. B. Gannushkin provided a classical definition of psychopathies, which clearly differentiated them from both neuroses and extreme Variants of the norm. Subsequently, the works of V. P. Osipov (1931), E. K. Krasnushkin (1940), E. A. Popov (1949), V. A. Gilyarovsky (1954), and most notably O. V. Kerbikov (1962)&mdashwho formulated a new dynamic concept of psychopathies that gained international recognition in psychiatry&mdashplayed a crucial role in advancing The Doctrine of psychopathies.

Epidemiology.

Data exist (Vaillant G., Perry J., 1980) indicating a very high prevalence of psychopathies&mdashranging from 5% to 15% of the total adult population; however, these findings require more rigorous epidemiological verification. Among other mental disorders, the "specific weight" of this pathology is also quite high, at approximately 5%. Men are affected by psychopathies roughly twice as often as women, and in adolescence, this ratio rises to three times as often.

ETIOPATHOGENESIS.

The causes of psychopathies are diverse and include hereditary factors, intrauterine influences, Birth injuries, Pathology of the early postnatal period, and others.

Environmental and adverse living conditions play a significant role in The Development of psychopathies (improper upbringing, psychotrauma, etc.). Improper upbringing is frequently driven by two primary factors: separation from parents and abnormal parental behavior. The risk of developing psychopathy is particularly high in single-parent families, in environments characterized by unhealthy relationships between parents, in the presence of paternal or maternal alcoholism, and amid low ethical and moral family standards. An antisocial family environment promotes a lack of proper social learning, causing the child to adopt inappropriate behavioral models. Such models can stem from parental behavior as well as surrogate norms prevalent in an environment substituting for the family.

Although The Role of genetic determination in personality anomalies is not yet fully proven, studies of monozygotic twins (some of whom were separated at birth) have shown that test results from twins reared apart closely matched those of twins raised together, thereby supporting METABOLISM/18.html">The Influence of genetics. It has been suggested that personality disorders represent extreme degrees of genetically determined variants of the norm; however, direct empirical evidence to test this hypothesis is currently lacking.

Numerous domestic and foreign researchers point to the role of cerebral pathology and Central Nervous system developmental disorders in the Pathogenesis of psychopathies. According to this concept, unlike a normal character shaped by improper upbringing or pedagogical neglect, psychopathy is distinguished by an inherent morphofunctional inferiority of The Nervous System that hinders adaptation to the external environment.

There is a hypothesis that minor Brain injuries in childhood ("minimal cerebral dysfunction") can lead to the development of epileptoid character traits and The formation of antisocial behaviors. Another frequently cited cause for such disorders is delayed brain development.

A wide range of psychoanalytical theories of psychological development have been developed to explain the origins of personality pathology. Sigmund Freud's theory places special emphasis on the events of the first five years of life. He posited that the critical stages of a child's libidinal development&mdashoral, anal, and genital (stemming from the axiom in Freudian psychoanalysis that children possess innate sexuality)&mdashmust be successfully navigated for normal personality development to occur. Fixation at any of these stages leads to personality disorders, up to and including mental illness. For instance, Freud attributed the formation of anankastic psychopathy to an arrest at the anal phase of development (libidinal fixation on the anal zone and pleasures associated with the ACT OF DEFECATION). He acknowledged the possibility of subsequent personality shifts later in life through identification with other individuals, though this was considered less significant than the negative impacts of early childhood.

C. G. Jung viewed personality development as a lifelong process, attributing the primary role to internal psychic processes rather than social influences. He developed the doctrine of archetypes, according to which an individual inherits the traits not only of their immediate relatives but of all ancestors collectively, thereby carrying a specific archetype that shapes their current personality traits. Jung was more intrigued by the transformations that occur in personality during later life, culminating on the threshold of death.

A. Adler rejected the Freudian theory of libidinal development, proposing instead that personality develops As a result of efforts aimed at compensating for feelings of inferiority.

Representatives of neo-psychoanalysis (E. Fromm, K. Horney, H. S. Sullivan) emphasized the role of social factors while assigning less importance to the biologically determined stages outlined by Freud. E. Erikson attributed the greatest significance in personality development and character pathology to the adolescent period.

Human life is continually accompanied by The impact of stressful situations. Due to specific personality traits, certain individuals become more vulnerable to developing emotional disorders. When faced with hardships, a person who has always worried over minor issues is far more likely to develop an anxiety disorder than someone less prone to worry. Under such a level of personality vulnerability, pathological behavior emerges solely as a response to pronounced stressor situations.

In individuals with more overt personality deviations, abnormal behavior manifests even in the absence of obvious psychotraumatic events. At times, these behavioral anomalies can be so significant that it is difficult to determine, based solely on the patient's current condition, whether they stem from underlying personality traits or a distinct mental disorder.

Psychic immaturity manifests as an increased susceptibility to outside influence, exaggeration, and fantasy in hysterical subjects; as emotional lability in emotionally unstable individuals; as weakness of will in dependent individuals with psychopathy; and as immature thinking in paranoid psychopathy.

Classification.

There are two main approaches to the classification of psychopathies. The first is descriptive, utilizing terms such as "weak-willed" or "aggressive." The second is descriptive-etiological, as it categorizes various types of psychopathy in accordance with the mental illness syndromes they resemble. For instance, a personality type characterized by eccentricity and emotional coldness is termed schizoid because these traits share similarities with certain symptoms observed in Schizophrenia patients; moreover, it is presumed that these personality traits and the mental illness share a common origin. Both approaches are integrated into the International Classification of Diseases.

According to O. V. Kerbikov, the leading factor in the development of psychopathies in some cases is constitutional ("nuclear psychopathies"), whereas in others, it is the psychogenic Influence of the surrounding environment ("pathocharakterological development"). The question of whether acquired forms of character pathology arising from psychogenic factors should be classified as psychopathy remains a subject of debate.

Since January 1999, psychiatrists in Ukraine have been using the ICD-10 classification of personality disorders:

✵ paranoid;

✵ schizoid;

✵ dissocial;

✵ emotionally unstable (impulsive and borderline types);

✵ histrionic (demonstrative);

✵ anankastic (obsessive-compulsive);

✵ anxious;

✵ dependent.

CLINICAL PICTURE.

Paranoid Personality Disorder.

The most characteristic personality traits in such patients include inertia, rigidity, inflexibility of emotional response, narrowness of interests, reduced ability to switch associations, egoism, excessive self-confidence, a tendency to form overvalued ideas that "occupy the psyche and influence all behavior" (P.B. Gannushkin, 1933), hypersthenia and hyperactivity, a tendency toward inadequate demands for justice, straightforwardness, distrust and suspicion, gloominess and vindictiveness, intolerance of any encroachment on their personal interests, neatness, and miserliness. Their sluggish and inert thinking is sharply affect-laden—the "crooked logic of affective thinking."

Paranoid psychopathies develop later than other forms, and they very frequently show a tendency toward pathological (paranoiac) personality development. In their "pure" form (without signs of pathological development), they are relatively rare.

Schizoid Personality Disorder.

Kretschmer mistakenly viewed schizoidity (pathological reclusiveness) as a transitional stage (without clear boundaries) between normality and schizophrenia. However, the premorbid profile in schizophrenia is far from always manifested as schizoid personality traits. Schizoids often come from families with no history of schizophrenia, and in a significant number of cases, "schizoidity" is fostered by adverse environmental conditions.

The most Characteristic Features of this type of psychopathy should be considered pathological reclusiveness, aloofness, introversion, and pathological affectivity (various, sometimes opposing tendencies may coexist; external coldness combines with mimosa-like hypersensitivity, and occasionally with affective explosiveness). Having no need for human communication and lacking The ability to establish lasting emotional connections, schizoids generally remain outside the group.

They are prone to daydreaming, fantasizing, pursuing Abstract problems, bizarre collecting, and creating strange works and pieces of art. Overall, such individuals are ill-adapted to life, poorly understand real circumstances, and are stubborn and touchy. Their thinking is largely abstract and autistic, their judgments are often eccentric, and their motor skills lack naturalness and harmony. Schizoids easily develop sensitive ideas of reference, paranoid and paranoid-type reactions, and related developments.

Dissocial Personality Disorder.

This disorder is a new classification category in domestic psychiatry. The four most significant features of dissocial psychopathy are: the inability to establish relationships of love and devotion, a tendency toward impulsive actions, a lack of remorse, and an inability to learn from negative experiences. Overall, this can be described as a deficit of higher moral emotions, where the drive for gratification becomes dominant.

The inability to form warm emotional attachments and love is accompanied by egocentrism and callousness. At the same time, the individual may be so heartless that it enables them to commit cruel or degrading acts against other people, inflicting pain and suffering. Such callousness often contrasts with external charm, which allows these individuals to form superficial and short-lived relationships. Sexual activity takes place without the expression of tender feelings. Marriage is often characterized by a lack of empathy for the partner and, at times, The Use of physical violence. Evidently, many cases of physical and psychological sadism, including in sexual relationships, are associated with manifestations of this personality disorder.

Characteristic impulsive behavior frequently manifests as frequent job changes and resignations, and in a broader life context—the inability to plan a life path, execute such a plan, or persistently strive toward a specific goal. Combined with a lack of guilt or remorse, impulsivity often leads to repeated offenses. This begins in adolescence with minor infractions, lying, and senseless hooliganism, accompanied by indifference to the feelings of others, violence, and callous disregard.

The pursuit of pleasure leads such individuals to substance abuse, alcoholism, vagrancy, sexual offenses, theft, and the like.

Emotionally Unstable Personality Disorder.

In terms of clinical manifestations, both types of this personality disorder (impulsive and borderline) largely correspond to the group of excitable psychopaths in Kerbikov's classification.

People with this type of personality disorder are unable to adequately control their emotions and are prone to sudden outbursts of uncontrollable anger. Such outbursts are not always confined to words, often being accompanied by physical violence, which sometimes leads to severe injuries.

The main feature of the impulsive type of emotionally unstable psychopathy is the inability to control affects. In the mixed type, dominant traits include hot-temperedness, extreme irritability reaching unbridled rage, domineeringness, selfishness, vindictiveness, spitefulness, and a predisposition to dysphoria.

Histrionic (demonstrative) personality disorder.

The core features of this personality disorder are considered to be a tendency toward dramatization, a craving for novelty, a drive to experience intense emotions, and an egocentric approach to interpersonal relationships.

Such individuals present themselves as far more significant and important persons than they actually are, constantly acting out a role as if unable to remain themselves. This is combined with fleeting enthusiasm, frequent boredom, and an insatiable craving for novelty. They are distinguished by extreme egocentrism, eccentricity, excessive vulnerability, and heightened yet superficial emotionality ("straw fire of feelings").

Egocentric manifestations in such personalities can be greatly exaggerated. To get what they want from others, these individuals are capable of emotional "blackmail," angry scenes, and demonstrative suicide attempts. Their intense, dramatized emotions are not actually all that profound, as histrionic psychopaths easily and quickly recover after "stormy scenes."

More so than in Other forms of psychopathy, disharmonious infantilism is evident here, alongside what is known in thinking as affective logic. These psychopaths are incapable of monotonous and systematic labor. In situations that are difficult for them, hysteroneurotic clinical pictures easily arise (most often in the form of hysterical physical monosymptoms—"lump in the throat," hysterical mutism, surdomutism, astasia-abasia, stocking- and glove-type hysterical paralysis, etc.), violent affective reactions (demonstrative weeping, rolling on the floor accompanied by self-inflicted injury, hysterical seizures, etc.), or reactions involving withdrawal into a world of dreams and fantasies. Psychogenic fantasizing in histrionic individuals can sometimes take on a pathological character, accompanied by the visualization of mental images, transformation into fantastic personas, significant narrowing of consciousness, and partial amnesia of real circumstances.

A notable trait of such individuals is a well-developed capacity for self-deception, where a person continues to believe they are right even when all the facts prove otherwise. Such individuals are capable of defending elaborate, convoluted lies long after other people have seen through them. In its extreme form, this behavioral pattern led Kraepelin to distinguish a group of pathological liars and swindlers among psychopaths.

Anankastic (obsessive-compulsive) personality disorder.

One of the most prominent features of anankastic psychopathy is poor adjustment to new living conditions and situations. Alongside traits such as punctuality and precision in carrying out tasks, one observes outdated views, a lack of flexibility in problem-solving, and a fear of the new.

Changes throw anankastic psychopaths off balance, which is why they prefer an established routine once and for all. Such subjects lack creative imagination and do not know how to capitalize on favorable opportunities. Precision in work typically manifests in an exaggerated form: preoccupation with trivial details, and a stubborn and often inappropriate drive for perfection that turns any labor into a heavy burden.

A characteristic trait of anankasts is a tendency toward hypersocial attitudes, but unlike epileptoids, directed not at others, but at themselves. This leads to a nearly constant sense of guilt associated with some wrongdoing, which suppresses any expressions of joy and pleasure. Sometimes this moralizing tendency also leads to an outwardly directed judgmental stance.

Inability to make decisions is also a typical trait—the inability to weigh the pros and cons of new situations or to arrive at definite Conclusions. Anankasts are afraid of making a mistake and continue to worry even after a decision has been made, lest their choice turn out to be wrong. This mental rumination literally exhausts a person, deprives them of the ability to enjoy life, and turns existence into a state of constant hesitation and suffering.

It is worth noting two other traits characteristic of anankastic disorder: high sensitivity to criticism and the opinions of others, and a tendency to accumulate negative emotions (resentment, anger) caused by someone else's Interference in their established way of life.

Anxious (avoidant) personality disorder.

The main feature of this personality disorder is persistent anxiety. Such subjects feel uneasy in company, fearing potential disapproval and criticism, and worrying about making a faux pas or embarrassing themselves. They are wary of the novel, highly cautious in contacts with unfamiliar people, and feel awkward while anticipating any unexpected events.

As a result, such individuals avoid social demands and minimize their circle of communication. At the same time, unlike schizoid psychopaths, representatives of this group are not emotionally cold. They yearn for social contacts but are unable to sustain them.

Dependent personality disorder.

Of greatest significance in this group is the marked weakness of higher volitional Functions and, consequently, an increased susceptibility to external influence, instability of interests, and an inability for sustained effort and tension (such people are "like a reed in the wind," Langeluddere, 1959). Their emotions are distinguished by volatility, instability, and superficiality, while their thinking is determined by the dominant affect. A tendency toward mood swings over any minor pretext is observed.

Disorganization, a tendency toward sudden, poorly motivated decisions, the ease with which pathological drives emerge, difficulty in developing adaptation mechanisms, a tendency to seek the path of least resistance, and instability of goal orientations frequently lead to antisocial forms of behavior (vagrancy, heavy drinking, gambling, sexual promiscuity, and perversions). Patients react to difficult situations in various ways: protest reactions, imitation, refusal, hysterical and explosive outbursts, etc.

People with a dependent personality disorder appear weak-willed and overly compliant, passively yielding to the desires of others. They lack energy and have little capacity for enjoyment. Such individuals avoid responsibility and lack self-confidence. Some achieve their goals by persuading others to help them while failing to acknowledge their own helplessness.

Mosaic psychopathy.

Among psychopathic personalities, one also encounters those in whom it is impossible to single out a predominant syndrome, as the psychopathic structure seems to be composed of disparate psychopathic manifestations. Such mosaic psychopathies were discussed by P.B. Gannushkin, E.K. Krasnushkin, O.V. Kerbikov, and others. In particular, P.B. Gannushkin pointed out that a characteristic feature of this group is the absence of a "main trend" characteristic of one or another type of psychopathy. Mosaic psychopathies are most typically characterized by combinations of psychopathic traits from the dissocial, histrionic, and emotionally unstable spectrums; combinations of sensitive and anankastic pathological properties occur less frequently. This mosaic pattern causes greater difficulty in adaptation. Compensatory mechanisms in these cases are more complex and multifaceted.

Treatment.

The general treatment scheme for psychopathies, especially during periods of decompensation and exacerbation, is structured as follows:

1. Attempting to appropriately modify the environment.

2. An individualized work regime is selected to train and strengthen nervous processes.

3. Various types of psychotherapy are applied.

4. Physiotherapy is employed (such as ionogalvanization with bromine, calcium, etc., Shcherbak's galvanic collar, and hydrotherapy).

5. Pharmacotherapy (primarily psychopharmacological treatment) is prescribed, taking into account the type of psychopathy, the form of clinical deterioration, and individual tolerance.

The goals of planned treatment should be modest, allowing for significant amounts of time to achieve them. Medications play a minor role in the treatment of psychopathies. If acute anxiety arises, the patient may receive short courses of anxiolytics or neuroleptics, but these drugs should not be prescribed for long-term use, as their therapeutic efficacy tends to diminish, and anxiolytics can additionally cause dependence.

Psychotherapy is most helpful for young adults who lack self-confidence, experience difficulties in building relationships, and struggle with career or life choices. Such individuals need to develop a strong motivation to work through their problems, which requires exploring their Perspectives and affective sphere. Psychotherapy is least effective in treating patients with antisocial personality disorder, although certain special forms of group psychotherapy can have a positive influence on some of them.

In most cases of psychopathy, psychotherapy (other than rational therapy) is not indicated, but guidance and support are beneficial. These functions are frequently assumed by a physician or psychologist, although an experienced social worker can work with many patients with equal success.

Regardless of The Nature of the disorder, the treatment plan aims to introduce changes that help the individual avoid difficult situations and provide greater opportunities to develop positive personality traits. Establishing a trusting relationship is crucial so that patients can discuss their mistakes and learn from them.

Undoubtedly, decompensations may occur in psychopathic individuals, but even during such episodes, the attending specialist must not view the treatment as a failure. Success is often achieved through a series of small, progressive steps that gradually move the patient closer to desired changes. These steps are frequently taken more actively during periods of decompensation, as it is precisely then that individuals become more willing to confront their real problems.

The physician should also help the patient develop more satisfying interpersonal connections, for instance, by encouraging participation in shared leisure activities, continuing education, and the like.

The methodology of dynamic psychotherapy in personality disorders differs little from that used in neuroses. Such treatment can be conducted individually or in a group Setting.

In individual treatment for psychopathy, less emphasis is placed on revisiting past events (as is common in the psychotherapy of neuroses) and more on analyzing current behavior. The specialist closely examines how the patient relates to others, copes with external challenges, and regulates their own emotions. This is known as character analysis. In the course of individual psychotherapy (predominantly rational therapy), psychoanalytic techniques involving the transference of current problems onto the therapist are frequently utilized. To highlight the discrepancy between the patient's habitual attitude toward others and the actual life situation, the therapist must engage in a significant degree of self-disclosure. At the same time, analyzing the physician's emotional response to the patient can serve as a vital indicator of how other people are likely to react to the patient.

Pharmacotherapy for psychopathies.

To relieve psychopathic agitation, the following are used: thioridazine (tiotixene/tisercin), diazepam (seduxen), tiapride (neuleptil), thioridazine (sonapax), and occasionally magnesium sulfate or chlorpromazine (aminazine).

For dysphoria and dysthymia, indicated medications include: tiapride 200–400 mg (starting dose 20–50 mg); tisercin 150–300 mg; chlorpromazine 300–500 mg; amitriptyline (triptizol) 100–200 mg (starting dose 10–25 mg); meprobamate (meprotan) 800–1400 mg; diazepam 20–60 mg; chlordiazepoxide (elenium) 30–80 mg (starting dose 10 mg).

For asthenic states, effective treatments include: intravenous 40% glucose infusions – 20.0 with 5% ascorbic acid – 1.0; low doses of Insulin – 6–8–12 IU; sydnocarb 10–25 mg (starting dose 5 mg); amizil 1–2 mg 3–5 times a day; sydnofen, etc.

In cases accompanied by insomnia, treatments include: tisercin up to 150–300 mg daily; chlorprothixene 20–400 mg; sonapax 10–50–75 mg; promethazine (pipolfen) 25 mg 2–3 times a day; nitrazepam (eunoctin) 5–30 mg; zaleplon (imovan/ivadol).

For obsessive-compulsive symptoms, effective drugs are: perphenazine (etaperazine) 60–120 mg daily; amitriptyline 100–200 mg (starting dose 10–25 mg); diazepam 20–60 mg; elenium 30–80 mg (starting dose 10 mg); meprobamate 800–1400 mg.

For hysteroneurotic states, indicated medications are: amitriptyline 100–200 mg (starting dose 10–25 mg); diazepam 20–60 mg; valerian preparations.

For clinical exacerbations in emotionally unstable and paranoid psychopathic personalities, the following are used: tisercin 150–300 mg; tiapride 200–400 mg (starting dose 20–50 mg); diazepam 20–60 mg, etc.

For anankastic and anxious psychopathies, depending on the patient's condition, prescriptions may include: imipramine (melipramine) 150–250 mg (starting dose 25 mg); amitriptyline 100–200 mg (starting dose 10–25 mg); sydnocarb 10–25 mg (starting dose 5 mg); deanol (centedrin) 10–30 mg (starting dose 10 mg).

For hysteric psychopathy, benzodiazepine tranquilizers are more commonly prescribed: elenium 30–80 mg; diazepam 20–60 mg (starting dose 5–10 mg); eunoctin 5–30 mg, etc.

For schizoid psychopathy, neuroleptics with activating properties are sometimes prescribed: alimemazine (theralene) 150–250 mg; thioridazine (melleril) 200–400 mg; perphenazine (etaperazine) 60–120 mg.

EXPERT ASSESSMENT.

Medical and social evaluation. Regardless of their form, psychopathic states provide grounds for referral to the Medical and Social Expert Commission (MSEC) for disability status only in exceptional cases. During decompensation of psychopathy, a temporary loss of work capacity typically occurs, requiring a medical sick leave certificate. Only in cases of prolonged and pronounced decompensation are patients rarely transferred to Group III disability, with employment recommendations tailored to each specific case.

Military-medical evaluation. According to Article 7 of the Order of the Minister of Defense of Ukraine, individuals suffering from decompensated forms of psychopathy are unfit for active military service in the Armed Forces and are removed from military registration. In cases of unstable compensation, they are unfit in peacetime, but fit for non-combat service in wartime.

Forensic psychiatric evaluation. The vast majority of individuals with psychopathic disorders are considered sane, as in most cases they understand the nature of their actions and can control them. During a forensic psychiatric evaluation, the primary focus is typically on the depth of psychopathic personality changes and the degree of their manifestation. Key diagnostic indicators include mental disharmony, the presence of psychological infantilism, adaptive capacity, the ability to regulate behavior, the frequency and severity of dynamic shifts over the lifespan, as well as age-related dynamics (the tendency toward either worsening severity or compensation).

In cases of profound personality pathology, psychopathic individuals are deemed insane, and medical measures are applied to them, meaning that psychopathy is equated to a mental illness.

Temporary dynamic shifts in psychopathy are assessed differently. If an offense is committed during a period of severe decompensation or an acute pathological psychopathic reaction, the individual's condition at the time of the offense may be regarded as a temporary mental disorder, rendering the subject legally insane.

If a state of decompensation or a psychopathic reaction develops after the commission of the offense, the trial is suspended, and the defendant is sent for compulsory treatment until the pathological symptoms subside. Afterward, they may face trial and be held accountable for the offense committed while they were of sound mind. Individuals suffering from psychopathy with psychotic features (pathological overvalued ideas or delusions) are classified as mentally ill and are considered insane.

All insane psychopathic individuals require medical intervention and are referred for compulsory or general treatment in psychiatric hospitals or placed under the supervision of a community psychiatrist. The duration of treatment is determined not by the "criminality" of the patient, but by the specifics of their mental state.

Review Questions.

1. Definitions of accentuated personality and psychopathy.

2. History of the study of personality disorders.

3. Etiological factors in the development of personality disorders.

4. Classification of personality disorders according to ICD-10.

5. Features of schizoid personality disorder.

6. Features of paranoid personality disorder.

7. Features of anankastic personality disorder.

8. Features of histrionic (demonstrative) personality disorder.

9. Features of emotionally unstable personality disorder.

10. Psychotherapeutic and pharmacological treatment of psychopathies.

11. Expert evaluation of psychopathies.