Personality Disorders Personality Disorders and Forensic Psychiatryand Forensic Psychiatry

Department of PsychiatryDepartment of Psychiatry11stst Faculty of Medicine Faculty of Medicine

Charles University, PragueCharles University, PragueHead: Prof. MUDr. Jiří Raboch, DrSc.Head: Prof. MUDr. Jiří Raboch, DrSc.

Disorders of Adult Personality Disorders of Adult Personality and Behaviour (F60-F69)and Behaviour (F60-F69)

F60F60 Specific personality disorders Specific personality disorders

F61F61 Mixed and other personality disorders Mixed and other personality disorders

F62F62 Enduring personality changes, not attributable to Enduring personality changes, not attributable to brain damage and disease brain damage and disease

F63F63 Habit and impulse disorders Habit and impulse disorders

F64F64 Gender identity disorders Gender identity disorders

F65F65 Disorders of sexual preference Disorders of sexual preference

F66F66 Psychological and behavioural disorders associated Psychological and behavioural disorders associated with sexual development and orientation with sexual development and orientation

F68F68 Other disorders of adult personality and behaviour Other disorders of adult personality and behaviour

F69F69 Unspecified disorder of adult personality and Unspecified disorder of adult personality and behaviour behaviour

F60 Specific Personality DisordersF60 Specific Personality Disorders

F60F60 Specific personality disordersSpecific personality disorders F60.0F60.0 Paranoid personality disorder Paranoid personality disorder F60.1F60.1 Schizoid personality disorder Schizoid personality disorder F60.2F60.2 Dissocial personality disorder Dissocial personality disorder F60.3F60.3 Emotionally unstable personality disorder Emotionally unstable personality disorder F60.4F60.4 Histrionic personality disorder Histrionic personality disorder F60.5F60.5 Anankastic personality disorder Anankastic personality disorder F60.6F60.6 Anxious Anxious ((avoidantavoidant)) personality disorder personality disorder F60.7F60.7 Dependent personality disorder Dependent personality disorder F60.8F60.8 Other specific personality disorders Other specific personality disorders F60.9F60.9 Personality disorder, unspecifiedPersonality disorder, unspecified

F60 Specific Personality DisordersF60 Specific Personality Disorders Specific personality disordersSpecific personality disorders

• severe disturbances in the personality and severe disturbances in the personality and behavioural tendencies of the individualbehavioural tendencies of the individual

• not directly resulting from disease, damage, or not directly resulting from disease, damage, or other insult to the brain, or from another other insult to the brain, or from another psychiatric disorderpsychiatric disorder

• usually involving several areas of the personalityusually involving several areas of the personality

• nearly always associated with considerable nearly always associated with considerable personal distress and social disruptionpersonal distress and social disruption

• usually manifest since childhood or adolescence usually manifest since childhood or adolescence and continuing throughout adulthood.and continuing throughout adulthood.

F60 Specific Personality DisordersF60 Specific Personality Disorders

Personality disorder is persistent and appears Personality disorder is persistent and appears already within late childhood and adolescence already within late childhood and adolescence being fully manifested in adulthoodbeing fully manifested in adulthood (d (diagnosing iagnosing after the age of 16-17 yearsafter the age of 16-17 years))

The disorder is usually associated with significant The disorder is usually associated with significant problems in occupational and social performanceproblems in occupational and social performance

Causes of personality disorders are mostly genetic Causes of personality disorders are mostly genetic though the influence of upbringing, parent-child though the influence of upbringing, parent-child relationship and social environment play also their relationship and social environment play also their roles.roles.

F60.0 Paranoid Personality F60.0 Paranoid Personality DisorderDisorder

Paranoid personality disorderParanoid personality disorder - characterized by - characterized by excessive sensitiveness to setbacks, persistent excessive sensitiveness to setbacks, persistent refusal to forgive insults and slights, suspiciousness, refusal to forgive insults and slights, suspiciousness, tendencies to misconstrue the neutral or friendly tendencies to misconstrue the neutral or friendly actions of others as hostile or contemptuous, actions of others as hostile or contemptuous, suspiciousness concerning fidelity of sexual partner, suspiciousness concerning fidelity of sexual partner, tendencies to experience excessive self-importance tendencies to experience excessive self-importance and preoccupation with unsubstantiated and preoccupation with unsubstantiated conspiratorial explanations of events.conspiratorial explanations of events.

Personality (disorder): Personality (disorder): • expansive paranoidexpansive paranoid• fanaticfanatic• querulantquerulant• paranoidparanoid• sensitive paranoid sensitive paranoid

F60.1 Schizoid Personality DisorderF60.1 Schizoid Personality Disorder

Schizoid personality disorderSchizoid personality disorder - few activities - few activities provide pleasure, emotional coldness, limited provide pleasure, emotional coldness, limited capacity to express either warm or hostile capacity to express either warm or hostile feelings with indifference to either praise or feelings with indifference to either praise or criticism, little interest in having sexual criticism, little interest in having sexual experiences with another person, preference for experiences with another person, preference for solitary activities, excessive preoccupation with solitary activities, excessive preoccupation with fantasy and introspection, lack of close friends fantasy and introspection, lack of close friends and marked insensitivity to prevailing social and marked insensitivity to prevailing social norms and conventions.norms and conventions.

F60.2 Dissocial Personality F60.2 Dissocial Personality DisorderDisorder

Dissocial personality disorderDissocial personality disorder::• gross disparity between behaviour and the prevailing social normsgross disparity between behaviour and the prevailing social norms• a callous disregard for the feelings of others, incapacity to maintain a callous disregard for the feelings of others, incapacity to maintain

enduring relationships, gross attitude of irresponsibilityenduring relationships, gross attitude of irresponsibility• very low tolerance to frustration, a low threshold for discharge of very low tolerance to frustration, a low threshold for discharge of

aggression and violenceaggression and violence• incapacity to experience guilt and to profit from experience incapacity to experience guilt and to profit from experience

including punishmentincluding punishment• a tendency to blame others, or to offer plausible rationalizations for a tendency to blame others, or to offer plausible rationalizations for

the behaviour bringing the patient into conflict with societythe behaviour bringing the patient into conflict with society

Personality (disorder): Personality (disorder): • amoralamoral• antisocialantisocial• asocialasocial• psychopathicpsychopathic• sociopathic sociopathic

F60.3 Emotionally Unstable F60.3 Emotionally Unstable Personality DisorderPersonality Disorder

Emotionally unstable personality disorderEmotionally unstable personality disorder::• characterized by a definite tendency to act impulsively without characterized by a definite tendency to act impulsively without

consideration of the consequences, together with affective consideration of the consequences, together with affective instabilityinstability

• outbursts of anger may lead to violence, particularly in response outbursts of anger may lead to violence, particularly in response to criticism (impulsive type)to criticism (impulsive type)

Two types may be distinguished:Two types may be distinguished:• impulsive typeimpulsive type - characterized predominantly by emotional - characterized predominantly by emotional

instability and lack of impulse control,instability and lack of impulse control,• borderline typeborderline type - characterized in addition by disturbances in self- - characterized in addition by disturbances in self-

image, aims, and internal preferences, by chronic feelings of image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide and by a tendency to self-destructive behaviour, including suicide gestures and attemptsgestures and attempts

Personality (disorder): Personality (disorder): • aggressiveaggressive• borderlineborderline• explosive explosive

F60.4 Histrionic Personality F60.4 Histrionic Personality DisorderDisorder

Histrionic personality disorderHistrionic personality disorder::• self-dramatization, pseudologia phantastica, self-dramatization, pseudologia phantastica,

exaggerated expression of emotions, enhanced exaggerated expression of emotions, enhanced suggestibility, shallow and labile affectivity, continual suggestibility, shallow and labile affectivity, continual seeking for excitement, appreciation by others, and seeking for excitement, appreciation by others, and activities in which the patient is the centre of attention, activities in which the patient is the centre of attention, over-concern with physical attractiveness together with over-concern with physical attractiveness together with inappropriate seductiveness, egocentricity, manipulative inappropriate seductiveness, egocentricity, manipulative behaviourbehaviour

Personality (disorder):Personality (disorder):• hystericalhysterical• psychoinfantile psychoinfantile

F60.5 Anankastic Personality F60.5 Anankastic Personality DisorderDisorder

Anankastic personality disorderAnankastic personality disorder::• characterised by feelings of excessive doubts, characterised by feelings of excessive doubts,

preoccupation with details, perfectionism interfering preoccupation with details, perfectionism interfering with task completion, excessive conscientiousness and with task completion, excessive conscientiousness and pedantry, rigiditypedantry, rigidity

• intrusion of insistent and unwelcome thoughts or intrusion of insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive-impulses that do not attain the severity of an obsessive-compulsive disordercompulsive disorder

Personality (disorder):Personality (disorder):• compulsivecompulsive• obsessionalobsessional• obsessive-compulsive obsessive-compulsive

F60.6 Anxious (Avoidant) F60.6 Anxious (Avoidant) Personality DisorderPersonality Disorder

Anxious (avoidant) personality Anxious (avoidant) personality disorder:disorder:• characterized by persistent and pervasive characterized by persistent and pervasive

feelings of tension and apprehension, feelings of tension and apprehension, preoccupation with being criticized or rejected preoccupation with being criticized or rejected by others, avoidance of social or occupational by others, avoidance of social or occupational activities because of fears of disapproval or activities because of fears of disapproval or rejection rejection

F60.7 Dependent Personality F60.7 Dependent Personality DisorderDisorder

Dependent personality disorderDependent personality disorder::• characterized by pervasive passive reliance on other people characterized by pervasive passive reliance on other people

to make one's major and minor life decisions, great fear of to make one's major and minor life decisions, great fear of abandonment, feelings of helplessness and incompetence, abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others, and passive compliance with the wishes of elders and others, and a weak response to the demands of daily lifea weak response to the demands of daily life

• llack of vigour may show itself in the intellectual or emotional ack of vigour may show itself in the intellectual or emotional spheresspheres

• there is often a tendency to transfer responsibility to others. there is often a tendency to transfer responsibility to others.

Personality (disorder):Personality (disorder):• asthenicasthenic• inadequateinadequate• passivepassive• self-defeating self-defeating

F62 Enduring Personality F62 Enduring Personality Changes, not Attributable to Brain Changes, not Attributable to Brain

Damage and DiseaseDamage and DiseaseF62F62 Enduring personality changes, not Enduring personality changes, not

attributable to brain damage and attributable to brain damage and diseasedisease

F62.0F62.0 Enduring personality change after Enduring personality change after catastrophic experience catastrophic experience

F62.1F62.1 Enduring personality change after Enduring personality change after psychiatric illness psychiatric illness

F62.8F62.8 Other enduring personality changes Other enduring personality changes F62.9F62.9 Enduring personality change, Enduring personality change,

unspecified unspecified

F62.0 Enduring Personality Change F62.0 Enduring Personality Change after Catastrophic Experienceafter Catastrophic Experience

Enduring personality change after catastrophic Enduring personality change after catastrophic experience:experience:

• present for at least two years, following exposure to catastrophic present for at least two years, following exposure to catastrophic stressstress

• characterized by a hostile or distrustful attitude toward the world, characterized by a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and feeling of "being on edge" as if constantly threatened, and estrangement.estrangement.

• enduring personality change after psychiatric illness (mostly enduring personality change after psychiatric illness (mostly schizophrenia) may appear due to the traumatic experience of schizophrenia) may appear due to the traumatic experience of suffering from a severe psychiatric illnesssuffering from a severe psychiatric illness

Personality change after: Personality change after: • concentration camp experiencesconcentration camp experiences• disastersdisasters• prolonged:prolonged:

captivity with an imminent possibility of being killedcaptivity with an imminent possibility of being killed exposure to life-threatening situations such as being a victim of terrorismexposure to life-threatening situations such as being a victim of terrorism

• torture torture

Treatment of Personality DisordersTreatment of Personality Disorders PsychotherapyPsychotherapy

• people who complain about lack of confidence and have people who complain about lack of confidence and have difficulties in making relationships are usually motivated for difficulties in making relationships are usually motivated for psychotherapypsychotherapy

• in emotionally unstable and dissocial personalities disorders in emotionally unstable and dissocial personalities disorders the patient should recognize the situations which provoke the patient should recognize the situations which provoke his/her pathological reactions and should manage to avoid his/her pathological reactions and should manage to avoid themthem

• psychotherapy of personality disorders is a very difficult task psychotherapy of personality disorders is a very difficult task and to reach a partial effect requests patient’s thorough and to reach a partial effect requests patient’s thorough motivationmotivation

PharmacotherapyPharmacotherapy helps in emotional disorders helps in emotional disorders• anxiolytics and SSRI antidepressants suppress anxiety and anxiolytics and SSRI antidepressants suppress anxiety and

depressive symptomsdepressive symptoms• lithium and other thymoprofylactics (carbamazepin, valproic lithium and other thymoprofylactics (carbamazepin, valproic

acid) reduces mood fluctuation and aggressive tendenciesacid) reduces mood fluctuation and aggressive tendencies

F63 Habit and Impulse DisordersF63 Habit and Impulse Disorders

F63F63 Habit and impulse disordersHabit and impulse disorders

F63.0F63.0 Pathological gambling Pathological gambling

F63.1F63.1 Pathological fire-setting Pathological fire-setting ((pyromaniapyromania))

F63.2F63.2 Pathological stealing Pathological stealing ((kleptomaniakleptomania))

F63.3F63.3 Trichotillomania Trichotillomania

F63.8F63.8 Other habit and impulse disorders Other habit and impulse disorders

F63.9F63.9 Habit and impulse disorder, Habit and impulse disorder, unspecifiedunspecified

F63.0F63.0 Pathological Pathological GGamblingambling Pathological gamblingPathological gambling::

• consists of frequent, repeating episodes of consists of frequent, repeating episodes of gambling which dominate patient’s life leading to gambling which dominate patient’s life leading to social, occupational, material and family social, occupational, material and family detrimentdetriment

• iit means an intense urge to gamble and t means an intense urge to gamble and preoccupation with ideas of the act of gambling preoccupation with ideas of the act of gambling which finally leads to large debts, criminal acting, which finally leads to large debts, criminal acting, loss of job and familyloss of job and family

PsychotherapyPsychotherapy and regime therapy is alike and regime therapy is alike the treatment of alcoholism (group the treatment of alcoholism (group psychotherapy — Anonymous gamblers, 12-psychotherapy — Anonymous gamblers, 12-steps psychotherapy, family therapy, etc.).steps psychotherapy, family therapy, etc.).

F63.1 Pathological Fire-Setting F63.1 Pathological Fire-Setting (Pyromania)(Pyromania)

PyromaniaPyromania::• characterized by attempts at, or acts of setting characterized by attempts at, or acts of setting

fire to property or objects without any apparent fire to property or objects without any apparent motivemotive

• connected with an intense interest in watching connected with an intense interest in watching fires burn and feelings of increasing tension fires burn and feelings of increasing tension before the act, and intense excitement before the act, and intense excitement immediately after it has been carried outimmediately after it has been carried out

F63.2 Pathological Stealing F63.2 Pathological Stealing (Kleptomania)(Kleptomania)

Kleptomania Kleptomania -- pathological stealing pathological stealing::• means that the patient suffers from intense means that the patient suffers from intense

impulses to steal objects that are not acquired impulses to steal objects that are not acquired for personal use or monetary gainfor personal use or monetary gain

• tthis disturbance may appear within the his disturbance may appear within the symptomatology of eating disorderssymptomatology of eating disorders

F63.3 TrichotillomaniaF63.3 Trichotillomania

Trichotillomania:Trichotillomania:• characterized by noticeable hair loss due to a characterized by noticeable hair loss due to a

recurrent failure to resist impulses to pull out recurrent failure to resist impulses to pull out hairshairs

F64 Gender Identity DisordersF64 Gender Identity Disorders

F64F64 Gender identity disordersGender identity disorders

F64.0F64.0 Transsexualism Transsexualism

F64.1F64.1 Dual-role transvestism Dual-role transvestism

F64.2F64.2 Gender identity disorder of Gender identity disorder of childhood childhood

F64.8F64.8 Other gender identity disorders Other gender identity disorders

F64.9F64.9 Gender identity disorder, Gender identity disorder, unspecifiedunspecified

For details see lecture Paraphilias.

F65 Disorders of Sexual F65 Disorders of Sexual PreferencePreference

F65F65 Disorders of sexual preferenceDisorders of sexual preference F65.0F65.0 Fetishism Fetishism F65.1F65.1 Fetishistic transvestism Fetishistic transvestism F65.2F65.2 Exhibitionism Exhibitionism F65.3F65.3 Voyeurism Voyeurism F65.4F65.4 Paedophilia Paedophilia F65.5F65.5 Sadomasochism Sadomasochism F65.6F65.6 Multiple disorders of sexual preference Multiple disorders of sexual preference F65.8F65.8 Other disorders of sexual preference Other disorders of sexual preference F65.9F65.9 Disorder of sexual preference, Disorder of sexual preference,

unspecified unspecified

For details see lecture Paraphilias.

F66F66 Psychological and behavioural disorders associated Psychological and behavioural disorders associated with sexual development and orientationwith sexual development and orientation

F66.0F66.0 Sexual maturation disorder Sexual maturation disorder F66.1F66.1 Egodystonic sexual orientation Egodystonic sexual orientation F66.2F66.2 Sexual relationship disorder Sexual relationship disorder F66.8F66.8 Other psychosexual development disorders Other psychosexual development disorders F66.9F66.9 Psychosexual development disorder, unspecified Psychosexual development disorder, unspecified

F68F68 Other disorders of adult personality and behaviourOther disorders of adult personality and behaviour F68.0F68.0 Elaboration of physical symptoms for psychological Elaboration of physical symptoms for psychological

reasons reasons F68.1F68.1 Intentional production or feigning of symptoms or Intentional production or feigning of symptoms or

disabilities, either physical or psychological disabilities, either physical or psychological ((factitious disorderfactitious disorder))

F68.8F68.8 Other specified disorders of adult personality and Other specified disorders of adult personality and behaviour behaviour

F69F69 Unspecified disorder of adult personality and Unspecified disorder of adult personality and behaviourbehaviour

For details see lecture Paraphilias.

The Law and Ordinary The Law and Ordinary Psychiatric PracticePsychiatric Practice

Consent to medical treatment and to hospitalizationConsent to medical treatment and to hospitalization - the patient should be informed about the treatment - the patient should be informed about the treatment procedures and probable side-effects of them to be procedures and probable side-effects of them to be able to give able to give „„informed consent”.informed consent”.

Compulsory admission and treatmentCompulsory admission and treatment (“admission (“admission without consent”) is realized in emergency situations without consent”) is realized in emergency situations (suicidal attempts, aggressive behaviour due to (suicidal attempts, aggressive behaviour due to mental disorder towards other people, disorders of mental disorder towards other people, disorders of behaviour endangering patient’s life). A compulsory behaviour endangering patient’s life). A compulsory admission should be reported to the local court admission should be reported to the local court within 24 hours; the court will decide within one within 24 hours; the court will decide within one week’s period whether the admission has been week’s period whether the admission has been justified.justified.

Civil LawCivil Law Testamentary capacityTestamentary capacity means that the individual is means that the individual is

able to make a valid willable to make a valid will. I. If there are some doubts f there are some doubts about it, the validity of the testament can be about it, the validity of the testament can be challengedchallenged. T. The testator should be of he testator should be of „„sound sound disposing mind” at the time of making itdisposing mind” at the time of making it..

FFour legal criteria:our legal criteria:1.1. the testator understands what a will is and what its the testator understands what a will is and what its

consequences areconsequences are2.2. hhe knows the nature and extent of his propertye knows the nature and extent of his property3.3. hhe knows the names of close relatives and can assess e knows the names of close relatives and can assess

their claims to his propertytheir claims to his property4.4. hhe is free from an abnormal state of mind.e is free from an abnormal state of mind.

Serious and persistent mental disorders cause Serious and persistent mental disorders cause incapacity of making decisions; the court appoints a incapacity of making decisions; the court appoints a guardian who is looking after patient’s affairs.guardian who is looking after patient’s affairs.

Criminal LawCriminal Law A person who committed a crime in a state A person who committed a crime in a state

of mental disorder undergoes psychiatric of mental disorder undergoes psychiatric examination:examination:• the expert gives a report on the mental state of the expert gives a report on the mental state of

the offender at the time of crime and on his/her the offender at the time of crime and on his/her present mental condition present mental condition

• according to the report conclusions the court according to the report conclusions the court decides about diminished or missing decides about diminished or missing responsibility of the offender and about fitness to responsibility of the offender and about fitness to pleadplead

• if the offender is dangerous to other people on if the offender is dangerous to other people on the ground of medical reasons the court can the ground of medical reasons the court can order compulsory treatment (psychiatric, order compulsory treatment (psychiatric, antialcoholic, antitoxicomanic, sexuological)antialcoholic, antitoxicomanic, sexuological)

Psychiatric (Court) ReportPsychiatric (Court) Report

Psychiatric reportPsychiatric report is worked out at the request of is worked out at the request of police, prosecutor, counselor, court or any part of police, prosecutor, counselor, court or any part of the action in court. It includesthe action in court. It includes• the data of the examinationthe data of the examination• family and personal historyfamily and personal history• the account of the crime given by the accused personthe account of the crime given by the accused person• present mental statepresent mental state• mental state at the time of the crimemental state at the time of the crime• fitness to pleadfitness to plead

Finally the expert replies the questions put by the Finally the expert replies the questions put by the court.court.

The court takes account of a report as of any other The court takes account of a report as of any other proof; it means that it is not binding for its final proof; it means that it is not binding for its final decision.decision.