Organic personality disorder

Organic personality disorder occurs after some types of brain injury. It can be a head trauma, an infection, for example encephalitis, or a result of a brain disease, such as, for example, multiple sclerosis. In human behavior there are significant changes. Often the emotional sphere and the ability to control impulsive behavior are affected. Although changes can occur due to the defeat of any part of the brain, for forensic psychiatrists of particular interest is the defeat of the forefront.

According to the requirements of ICD-10 for the diagnosis of organic personality disorder, in addition to evidence of brain disease, trauma or dysfunction, two of the following six criteria must be present:

• decreased ability to persevere in targeted activities;
• affective instability;
• violation of judgments of a social nature;
• suspicion or paranoid ideas;
• changes in the pace and fluency of speech;
• altered sexual behavior.

[1], [2], [3], [4],

Organic personality disorder and behavior

The reason for attention of forensic psychiatrists to this condition is the absence in connection with it of normal control mechanisms, increased egocentrity and loss of normal social sensitivity. People with a previously benevolent person suddenly commit a crime that does not fit into their character at all. Time proves the development of their organic cerebral state. Most often, this pattern is observed with anterior fracture of the brain. It is suggested that the most relevant for forensic psychiatry aspect of the defeat of the frontal department is associated with a violation of the control of performance, which, in turn, is defined as the ability to plan and anticipate the consequences of their behavior. The behavioral features of such subjects reflect the characteristics of their past personality and their emotional response to the loss of their capabilities, as well as the inadequacy of brain function.

Organic personality disorder and law

Organic personality disorder is accepted by the court as a mental illness. A disease can be used as a mitigating circumstance and, perhaps, as a basis for deciding on the direction of treatment. Problems arise with individuals with a somewhat antisocial personality, who also had brain injuries that aggravated their antisocial attitudes and behavior. Such a patient, because of a stable antisocial attitude to people and situations, increased impulsiveness and indifference to the consequences, can be very difficult for ordinary psychiatric hospitals. The case can also be complicated by anger and depressed subject related to the fact of the disease. There is a temptation to describe such a patient as a person with a psychopathic disorder that can not be cured, in order to transfer it to the care of the punishment system. And although in soft cases such a step may be adequate, in fact it reflects the lack of specialized mental units capable of coping with such a problem. It should not be forgotten that Art. 37 of the Mental Health Act provides for the possibility of applying a warrant of custody. Such an order may be an adequate measure if the offender complies with the supervision regime and if the specialized unit is able to provide it with outpatient care.

Case description:

A 40-year-old man, who previously held a responsible post in the civil service, developed multiple sclerosis in his thirties and a half. The disease, initially manifested in the cerebral form, gradually progressed with very small periods of remission. Magnetic resonance spectroscopy showed in both frontal regions of the demyelination zone. As a result, his personality changed a lot: he became sexually disinhibited and began to release insulting remarks about female employees in the service. The man was dismissed on medical grounds. He developed a promiscuity: he approached the street with women with obscene sexual suggestions. Several times after the denial of women on the street, he committed an offensive attack on them. Irritability and aggressiveness also grew in him. In connection with the conviction of a number of indecent attacks against women in accordance with Art. 37/41 of the 1983 Mental Health Act, he was placed in a special institution with an enhanced security regime. The disease continued to progress in the next two years, and at this time the frequency of his attacks on female service personnel and other patients increased. For this reason, he was finally transferred to a special hospital.

In the early 70-ies of the XX century, a number of authors proposed the term "episodic dyscontrol syndrome" (English episodic dyscontrol syndrome). It was suggested that there is a group of people who do not suffer from epilepsy, brain damage or psychosis, but who aggressively behave due to deep organic personality disorder. At the same time aggressive behavior is the only symptom of this disorder. The majority of people who are endowed with this diagnosis are men. They have a long history of aggressive manifestations that go away in childhood, and also often unfavorable family background. The only evidence in favor of such a syndrome is that these individuals are often present with EEG-anomalies, especially in the temporal region. They also describe an aura similar to that characteristic of temporal epilepsy. It is suggested that there is a functional abnormality of the nervous system, which leads to increased aggression. According to Lishman, this syndrome is located on the border of an aggressive personality disorder and temporal epilepsy. Lucas gave a detailed description of this disorder. He points out that in ICD-10, this behavioral constellation falls into the section of organic personality disorder in adults. Evidence of the underlying disorder of epilepsy is not enough, and it can be singled out separately as an organic brain disease, but, according to Lucas, it is not worth it.

Similar statements were made with regard to attention deficit hyperactivity disorder. According to ICD-10, this condition is recognized in children as a hyperkinetic disorder of childhood and is defined as "general." "General" means that hyperactivity is present in all situations, that is, not only in school or not only at home. It has been suggested that the most severe forms of this condition are the consequence of minimal brain damage, and they can persist in adulthood and manifest themselves in disorders associated with impulsivity, irritability, lability, explosiveness and violence. According to available data, 1/3 of them in childhood develop an antisocial disorder, and most of this group in adulthood will become criminals. In childhood, the therapeutic effect can be achieved with the help of drug therapy stimulants.

[5], [6], [7], [8],

Organic psychosis

Organic psychoses are included in the ICD-10 in the section of other mental organic personality disorders due to brain damage, its dysfunction or physical illness. Their general criteria are:

1. evidence of the presence of brain disease;
2. communication of disease and syndrome over time;
3. recovery from a mental disorder in the effective treatment of its cause;
4. There is no evidence of the presence of another cause for this syndrome.

Organic personality disorder can be represented by both neurotic forms and

1. an organic hallucinosis;
2. organic catatonic disorder;
3. organic delusional (schizophreniform) disorder;
4. organic mood disorders (affective disorders).

The clinical picture is expressed in a severe psychotic state, which is based on an organic cause. Behavior of the subject simply reflects psychosis and its content, i.e. The paranoid state can be expressed in suspicious and hostile behavior.

Organic psychoses and law

Under the Mental Health Act, psychoses are clearly accepted as a mental illness and, therefore, can serve as a basis for referral to treatment, and also be considered as a mitigating factor, etc. If the disease occurs after a head injury or other trauma, there may also be grounds for material compensation.

Organic personality disorder caused by psychoactive substances

There are organic personality disorders that can be caused by any substance, and the most common of these substances is alcohol. There are also a variety of medications (sedatives, stimulants, hallucinogens, etc.) that can be used legally and illegally, and can cause a variety of mental disorders. The most common disorders are listed below:

1. Intoxication due to the intake of excessive amounts of substance with a change in mood, changes in motor skills and changes in psychological functioning.
2. Idiosyncratic intoxication (in the Russian translation of ICD-10, "pathological intoxication"), when the apparent intoxication is caused by a very small dose of the substance, which is due to the individual characteristics of the response in this person. Here you can observe a variety of effects, including delirium and changes in the autonomic nervous system.
3. Undo effects. A variety of effects that can be caused by a sudden discontinuation of the drug, to which a person has developed dependence. These can be delirium, changes in the autonomic nervous system, depression, anxiety and tremors.
4. Mental illness. It can be differently related to the use of psychoactive substances, that is, to act

• as a direct effect of the substance, for example amphetamines and their derivatives, cocaine, lysergic acid diethylamide or steroid-type drugs;
• as the effect of sudden withdrawal of a substance, for example paranoid psychosis after alcohol withdrawal;
• as an effect of chronic use of a substance, for example alcoholic dementia;
• as a precursor of relapse or increased symptomatology in patients suffering from schizophrenia, such as cannabis.

Intoxication

The Mental Health Act unambiguously excludes the mere abuse of alcohol and drugs from among the conditions covered by this legal act. In general, if a person takes a prohibited drug (including alcohol), he is considered responsible for any actions he has committed in intoxication from taking this drug. Disinhibition or amnesia due to taking a psychoactive substance is not an excuse. Exceptions are listed below - from (1) to (4). In this case, subparagraphs (1) and (3) refer to "involuntary intoxication" and may lead to the acquittal of the suspect.

The situation when a person is deceived by a deception to take a substance, and he does not know about it (difficultly provable).

The situation in which the reaction to a substance is purely individual and unexpected - for example, severe intoxication after taking a very small amount of a substance. So, there were statements about cases of "pathological intoxication" in some individuals after very small doses of alcohol, especially if they had a history of brain damage. In such cases, after taking a small amount of alcohol follows a brief flash of severe aggression in the state of complete disorientation or even psychosis with subsequent sleep and amnesia. This position has its supporters and opponents. This situation has not yet been fully resolved, but nevertheless, protection on this basis was used in courts, especially when the clinical picture of an organic personality disorder is proven.

The situation when a person gives an adverse reaction to a medication prescribed to him by a doctor. So, for example, the sedative effect of the drug may cause some people to have completely unusual reactions, not related to their usual behavior. In this case, actions may be committed by such person unintentionally.

Edwards described the criteria for establishing a genuine link between intoxication from taking the drug and a committed crime. So, there must be a clear connection between the medicine and the act. An adverse reaction must be documented by the person authorized to do so; the action should not be a manifestation of the illness that the patient suffers, and he also should not take any other drugs that might trigger a similar reaction; the medication and reaction should be appropriately interrelated in time; and this reaction should disappear after discontinuation of the medication.

The situation when the degree of intoxication turns out to be such that the subject becomes unable to form an intention. The courts are very skeptical about the defense built on this basis, as they fear that a successful protest can cause a shaft of similar statements from criminals who committed the crime while being under the influence of alcohol. It has now been established that the accused will not be acquitted for crimes with original intent (for example, unintentional murder, assault and unlawful wounding) if he, conscious of the consequences of this step, voluntarily accepted alcohol or drugs and thus deprived himself of the opportunity to govern himself or ceased to realize his actions. In the case of crimes with special intent (intentional murder or theft), there will be the possibility of protecting the communication "with the lack of intention." In case of a deliberate killing, the charge can be reduced to an involuntary murder.

Quite often, people who were at the time of committing a crime in severe intoxication state that they do not remember anything about the crime, and this is all "due to alcohol". The study of relevant statements almost always confirms that the subject's behavior is very understandable in this situation, regardless of whether he was drunk. In such cases, protection is not allowed, based on the effects of intoxication. However, after sentencing, courts often sympathize with people who want to get rid of alcohol or drug addiction, and make decisions about probation with the condition of treatment of dependence, if, of course, this is acceptable in this particular case and the crime committed is not very serious.

In some cases, the psychiatrist may be asked about the effect of alcohol taken against the background of taking the medication on the person's mental state or degree of intoxication. The level of alcohol in the blood varies depending on the age of the subject, the type of drink (carbonated beverages are absorbed more quickly), the presence of food in the stomach, the structure of the body and the rate of devastation of the digestive tract (under the influence of certain drugs). Euphoria is noted at a level of 30 mg / 100 ml, driving disorders - at 50, dysarthria - at 160 with a possible loss of consciousness above this level, and death - at a level above 400. At 80, the risk of a road accident is more than twice as high, and when 160 - more than ten times. The rate of alcohol metabolism is approximately 15 mg / 100 ml / h, but there may be large discrepancies. Many drinkers have a higher metabolic rate if they do not have liver damage, since in the latter case the metabolism slows down. The Court of Appeal permitted a reverse calculation, proceeding from a known level of substance in the blood, and present it as evidence. Psychiatrist may be asked to comment on factors that could somehow affect the case in question.

Disorder of withdrawal

The court may take as an extenuating factor the mental disorder caused by the discontinuation of taking the substance, of course, in cases where there was no reason to expect this disorder from the subject.

[9], [10], [11], [12], [13],

Organic personality disorder associated with substance abuse

In the event that the offense is committed during a psychiatric illness of a person caused by a psychoactive substance, the courts are willing to consider this as a mitigating factor and, subject to medical advice, refer such persons to treatment, of course, if such a direction seems fair and reasonable to them. On the other hand, psychiatrists do not always agree to recognize a patient as a patient with a temporary disorder due to substance misuse, especially if the patient has antisocial tendencies. The difficulty here is that some people of mental illness are preceded by the use of drugs, and the manifested mental illness does not pass quickly, but begins to acquire the characteristics of a chronic psychosis (for example, schizophrenia), whose treatment requires hospitalization and supportive care.