Psychopathic disorder

In 1994, the report of the working group of the Ministry of Health and the Ministry of Internal Affairs on such a mental disorder as a psychopathic disorder headed by Dr. John Reed was published. The report contained a very informative review of the psychopathic disorder, as well as 28 recommendations for the future, some of which formed the basis for changes in legislation.

The 1997 Offenses (Sentences) Act contained changes to the 1983 Mental Health Act, in particular regarding the management of cases of persons isolated from society within the category of psychopathic disorder. For the period of writing this chapter, the text of the Fallon Inquiry investigation in the Ashworth Hospital personality department has been read with 58 recommendations that are currently being studied by interested parties. In 1999, the report of the working group of the Ministry of Health and the Ministry of Internal Affairs on psychopathic disorder will be heard.

What is a psychopathic disorder?

Walker, quoting Pinel, shows that psychiatrists have for many years been inclined to treat individuals with severe personality disorders and manifestations of aggression and irresponsibility as objects of psychiatric treatment. Over time, there have been changes only in the level of understanding of the topic and in diagnostic terms. Among the latter were manie sans délire, moral madness, moral imbecility, psychopathy, degenerative constitution, constitutional inferiority, moral insufficiency, sociopathy, and others.

The term "psychopathy" arose at the end of the 19th century in Germany and was originally applied (and still used in continental Europe) to all personality disorders. For the first time, the term was narrowed in the United States, where it was applied to individuals exhibiting antisocial behavior, and it was in this interpretation that it was imported into England. The term was included in the Mental Health Act of 1959 as a "psychopathic disorder". This general term has replaced the terms "moral madness" and "moral defect", previously used in the laws on mental insufficiency. Despite ongoing discussions about the meaning of using this term, it is nevertheless preserved in the Mental Health Act of 1983. As noted in the Butler Report, the legal term "psychopathic disorder" does not imply a separate diagnostic unit under this name; rather, it is a generic term used for legal categorization and encompassing several specific diagnoses. On the other hand, reliable specific diagnoses in this area have yet to be developed. To avoid confusion, the term "psychopathic disorder" should be used solely as a legal concept. However, unfortunately, confusion can not be avoided completely, and as we will see from the content of this chapter, sometimes it is necessary to address psychopathic disorder as a clinical condition for the purpose of discussing the available literature.

This legal term includes a number of personality disorders according to ICD-10 and B8M-1U. For example, although dissocial personality disorder according to ICD-10 (B60.2) and antisocial personality disorder according to B5M-1U (301.7) are closest to the clinical understanding of the term "psychopathic disorder", the legal term "psychopathic disorder" is also used in relation to Some individuals with a paranoid personality according to ICD-10 (B60.0), emotionally unstable personality disorder (including impulsive and borderline types - BB0.Z0, B60.31) for ICD-10, borderline personality disorder (301.83) and schizoid personality stnogo disorders in ICD-10 (BbOL). In fact, according to the definition of the Mental Health Act, it includes any personality disorder that results in "a strong, irresponsible and anomalously violent behavior." In addition, people with sexual deviations combined with personality disorders were included in this legal category of the psychopathic disorder, although in the psychiatric sense they can also be classified as an impersonal disorder and attributed to such groups B5M-1U and ICD-10 as sexual sadism / sadomasochism , pedophilia and exhibitionism.

Because of the problem of definition, Butler's Commission recommended to abandon the term "psychopathic disorder". But nevertheless, despite all the difficulties, the term was retained in the Mental Health Act of 1983, although with some important practical changes. First, it is now clear that the diagnosis of a psychotic disorder by the 1983 Act alone is not enough to apply a warrant for treatment. Before deciding on the referral for treatment, it must also be shown that medical treatment is likely to alleviate the condition of the subject or prevent its deterioration. And, secondly, it is possible to apply the Law of 1983 for involuntary referral to treatment in the case of a psychopathic disorder within the civil law (subject to the satisfaction of treatment conditions) of persons of any age, and not only persons under the age of 21 years, as provided for The law of 1959.

The curability of a psychopathic disorder

Despite the positive aspect of inclusion in the criterion of hospitalization of the criterion of "curability", among psychiatrists there is currently no agreement as to what is curable and what is not. This is well illustrated in a review of the Sore of the opinions of all forensic psychiatrists in England, Scotland and Wales. In this review, counseling forensic psychiatrists answered questions on three brief descriptions of cases that could be classified as a psychopathic disorder. The least agreement was on A's case (a schizoid man, possibly a pre-psychotic patient): 27% of psychiatrists considered it incurable, and 73% found it treatable. Most of all the consent was on the occasion of B (a woman suffering borderline personality disorder): 5% of psychiatrists considered her incurable and 95% - curable. In 1993, the results of this survey were reviewed by the Working Group of the Ministry of Health and the Ministry of the Interior for a psychopathic disorder, headed by Dr. John Reed.

Despite this lack of agreement, patients are hospitalized and treated within the category of psychopathic disorder. When considering the issue of hospitalization under the Mental Health Act, it may be more appropriate to treat curability as a perfection, which, as everybody knows, has a different view. It would be wrong to declare a person curable and hospitalize him if you do not have adequate services at your disposal to effect treatment. So, for example, if for treatment it takes more than one year and a large volume of psychotherapy, and your service is able to provide only short-term hospitalizations and a little psychotherapy, then the person in such service is incurable. Special orders of the National Health Service allow for treatment in another territory (additional contractual directions), but then there are ethical problems associated with the need to make decisions about how far the patient can be directed in the absence of adequate services in the region.

Isolation from society due to a psychopathic disorder involves consideration of the question of curability upon admission, but not at discharge, that is, a patient who has become incurable can not be discharged on this basis, unless there is a decision of the tribunal that there is no likelihood of curability in the case of continued isolation of the patient from society. This was unequivocally shown in the case examined by the Mental Health Tribunal in Canon Park in which a stationary patient at some stage of hospitalization refused to accept the only treatment that was believed to be able to help her-psychotherapy. The patient's defense used the following argument: if the patient was now incurable (since in the event of refusal to cooperate in psychotherapy there were no other treatment options for her), then she is subject to discharge (despite her danger and the fact that she was kept in a department with a strengthened safety mode). The Tribunal refused to issue this patient. The patient asked for a review in the District Court (part of the Court of Appeal), which abolished the decision of the tribunal, which meant the patient's discharge. In conclusion, LJ Mann of the District Court said: "I am nevertheless convinced that on the grounds given by J. Sedley and enacted by Parliament, an incurable psychopath is not to be isolated, no matter what danger he poses."

This decision caused serious concern: at the present time in hospitals with strict security regime there are many highly dangerous "incurable" psychopaths - means that now all of them should be released? The Tribunal filed an appeal, and subsequently this decision was quashed by the full session of the Court of Appeal. The Court of Appeal noted that the formulation of the Mental Health Act is such that even if a "cure test" is applied at the stage of hospitalization, it is not necessary to take it into account when considering the continuation of the patient's care in the hospital. At this stage, the tribunal must consider the continuation of the detention in the hospital, that is, use a "compliance test". Therefore, if it is considered that a person who is currently refusing from treatment or who has become otherwise incurable, may become curable during a subsequent hospital stay, continuation of hospitalization is a legal and appropriate measure. The decision of the tribunal in Canon Park was again considered in another case, but in its essence the position of the court did not change.

Primary and secondary "psychopaths"

In the past, practitioners have divided antisocial personalities into primary and secondary (neurotic) psychopaths. This division is now not found in ICD-10, nor in DSM-IV, but many psychiatrists still consider this concept useful. The syndrome of the primary psychopath is described by Cleckley. At first glance, these people seem normal, charming, intelligent, they easily communicate with others, without excessive shyness. However, if you look at their history, then there is an extremely egocentric, impulsive and bizarre behavior that ultimately contradicts the interests of this subject. Clashes with law enforcement agencies may not be for an indefinitely long time, as these people are smart and charming, and they can achieve a high position in society until their true essence is revealed. Sometimes such a subject tells you a story of an early psychological trauma, as usually this is of interest to psychiatrists, but subsequent investigation does not confirm this data. Their behavior can not be understood in terms of ordinary psychology. Cleckley argues that such psychopaths have an innate brain function disorder, resulting in dissociation of emotions (for example, feelings of guilt) and words. Therefore, Cleckley considered primary psychopaths virtually incurable. The concept of primary psychopathy is widely used in some research and psychiatric institutions, but in general in England it has not received much support among clinicians. Secondary psychopaths resemble the description of antisocial individuals with severe anxiety. Their personality is largely understood in the light of the psychological trauma experienced by them at an early age. Clinical manifestations of secondary psychopathy are usually more visible - these are the worst coping skills and frequent self-harm.

Psychopathic disorder and psychotic symptoms

Comparatively brief periods of the manifestation of psychotic symptoms are often noted in prisons and hospitals with an enhanced safety regime among persons classified as psychopathic disorder. They are observed in almost all serious personality disorders, usually at times of stress, but sometimes they happen without any obvious reason. Omet studied 72 women with borderline personality disorder and are in a special hospital. He described in them a cyclical pattern of affective disorder (which is often similar to endogenous), the main characteristics of which are anxiety, anger, depression and stress. After the growth of these symptoms (within a few hours or days), they note a compulsion of external response in the form of a criminal (for example, arson) or autodestructive behavior. The response should be temporary relief of symptoms. Then the cycle repeats.

Management of such periods can be difficult, since these states are difficult to introduce into a controlled channel. In psychotic periods, there is usually a paranoid state with delusions and hallucinations. On the psychotic experience, the subject can react with tension, hostility and destructiveness, as, for example, in an affective disorder. Difficulties in managing cases are the same, although antipsychotic pharmacotherapy usually gives a fairly quick effect. Some of these individuals become more stable if they take antipsychotics on a regular basis. Moreover, comparatively low doses may be sufficient here.

Psychopathic disorder, mental illness and substance abuse

Psychiatrists often meet with people who have a history of a long history of disorganizing behavior and personal difficulties, including weak control over impulsive actions, repeated and deliberate self-harm, violence directed against property and violence against others. Often such persons also abuse drugs, and they have episodes that are very similar to psychotic. They can present serious difficulties both from the point of view of organizing the necessary assistance for them and from the point of view of diagnostics, since they are too disorganized to be placed in an ordinary psychiatric ward. They usually drift between psychiatric services and the criminal justice system, but they can also fall into the category of the homeless. Simple answers to the question of how to help these people, no, unless, of course, they are placed in a department with an enhanced security regime. Such hospitalizations are often made through a prison or a police station. Quite often, forensic psychiatrists discover a psychotic illness in such patients, who are kept in a structured environment and strengthened surveillance, based on personal problems. Long-term hospitalization can often lead to significant functional improvement in such a patient.

Treatment of psychopathic disorder

The treatment of adults with psychopathic disorder has been extensively reviewed in a review by Dolan and Coid in a study commissioned by the Ministry of Health and the Ministry of the Interior. As a result of this study, a document entitled "Review of medical and social services for criminals suffering from mental disorders, as well as other people in need of similar services", led by Dr. John Reed. The need for such a review was dictated by the lack of consensus on the optimal treatment approach, as well as the principled curability of such patients. We will quote some statements reflecting the inadequacy of our knowledge regarding the treatment of "psychopathic disorder":

• "Of course, there is no evidence to support or indicate that psychiatry has managed to find a therapy that cures or deeply changes a psychopath" (Cleckley, 1964)
• "Looking through the literature on the topic of treating a personality disorder, you are involuntarily amazed at how little we know about these conditions" (Frosch, 1983)
• "The literature on the treatment of antisocial personality disorder is clearly inadequate" (Quality Assurance Project, 1991)
• "When analyzing scientific literature on the topic of treating psychopathy, two things inevitably strike: the first is that the scientific studies of the outcome of the treatment of psychopathy are very few and of poor quality; and the second one (which, incidentally, causes more concern) is that, despite the fact that the authors have been summarizing and commenting on these studies for several decades, there have been no obvious achievements to date "(Dolan and Coid, 1993)

Age aspect

Before turning to the treatment of psychopathy, it is important to recognize the characteristics of the natural development of personality disorders found in the "psychopath". There are no clear and consistent answers based on the data of scientific research, but it is generally accepted that certain personality disorders in some people decrease with age, in particular, it concerns borderline, antisocial and hysterical personality disorders. Other disorders are more stable. Among them, paranoid, obsessive-compulsive, schizoid, avoiding, dependent and passive-aggressive personality disorder. For those cases that improve over time, changes begin to occur after reaching middle age.

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

Treatment of psychopathic disorder in prison

The prisons of many countries have tried for many years to use a variety of approaches to reform or rehabilitate criminals-recidivists, using religious instruction, education, introducing working ethics, punitive methods, etc. Typical psychiatric approaches are as follows:

Therapeutic Center Herstedwester, Denmark

This center, opened in the 30s of the XX century, was the first prison to attempt to treat psychopaths with the help of methods of psychotherapy. The center was headed by a psychiatrist Dr. Sturrup, and the work in it was built on the principles of the therapeutic community. Initially, to motivate prisoners to participate in any activity, the emphasis was on the indefinite nature of the sentence, that is, participating in programs, prisoners could earn themselves a release through the achievement of an appropriate improvement. The prison claims that they have managed to achieve lasting improvements in their clients. However, the comparative study described in the Butler Commission report indicates that there is no difference in the final indices of criminal recidivism committed by former Hurdsteader prisoners compared to similar prisoners from a conventional prison, although during the period of treatment they did have obvious improvements.

Prison Grendon Underwood, England

This is a 200-seat prison, planned in the 1930s, created in 1964, based on the hypothesis that crime may be a consequence of neurosis, which, in turn, can be cured. In practice, this prison was used to treat group criminals with criminals suffering from personality disorders who could work in the group for their own benefit and who have already served a prison sentence. Prisoners went to Grendon Prison in the direction of the prison medical service after the punishment was imposed. The final selection was carried out on site by the staff of the Grendon Prison, based on the intellectual level of the prisoner, his ability to verbally express his ideas, his abilities and desires to work in groups and to prove some personal achievements. The regime in Grendon Prison during the period 1987-1994 is described in detail by Genders & Player. Gunn showed that the attitude and behavior of Grendon prisoners improved compared to those of prisoners in other prisons, but at the same time the beneficial effect of the regime in Grendon after returning to the community was confronted with a harsh reality of the environment. It was found that random factors in the community (for example, employment, marriage) were no less important in the long run than the entire Grendon experience. In general, after ten years in the community, the recidivism rates of former Grendon prisoners were the same as in the equivalent group from a conventional prison, although more motivated and more intellectually developed individuals could be helped more. The Cullen study tracked the events of 244 prisoners with fixed sentences for more than 2 years after being released from prison. It turned out that those prisoners who stayed in Grendon less than 18 months gave a 40% relapse rate, and those who were in Grendon for more than 18 months - 20%.

It should be mentioned here that in the interval between the studies of Gunn and Cullen the population of prisoners has changed. During Gunn's research in prison, the percentage of young people serving shorter sentences for self-serving crimes was higher.

Wing From Prison Parkhurst, England

This wing, closed in 1995, was intended for men who suffer from personality disorders, accompanied by high levels of tension, emotional lability, violence and behavioral disorders (self-harm, attacks of impulsiveness, destructive behavior, reducing stress levels). Such men are unable to cope with the usual prison regime and are too disorganized (too impulsive or aggressive) to count on some success in Grendon Prison. The existing regime helped these extremely upset prisoners in a psychic sense to serve their punishment. This was achieved through greater flexibility and greater attention to prisoners (pharmacotherapy and psychological counseling) than in an ordinary prison. There was a general clinical impression of a significant reduction in the number of violent and disorganized incidents during the stay of prisoners in this wing. Studies of the long-term effects of this service were not conducted. A study of a similar unit at Barlinny Prison in Scotland (which is now closed) notes a rapid reduction in violent behavior in the unit and indicates a reduction in the number of subsequent relapses.

Treatment of psychotic disorder in the hospital

Ordinary hospital

Ordinary hospitals accept patients with personality disorders during crises, that is, during periods of depression, a high level of anxiety or during psychosis, and this can be useful in terms of preventing harm that such a patient can inflict on themselves or others. At the same time, most believe that they can not treat such patients on a long-term basis because of their persistent disorganizing behavior, which does not recognize any authority that they are unable to change. Perhaps, this reflects the general trend of decreasing in recent years the number of warrants for hospitalization, appointed by courts to persons suffering from psychopathic disorder.

Special hospital

In recent years, there has been a decline in the placement of patients with psychopathic disorder in a special hospital: from about 60 per year in 1986-1990 to 40 per year in 1991-1996. This is less than one for every 2,000 people convicted of violent or sexual crimes. Treatment of psychopathic disorder in the Brodmur hospital includes psychotherapeutic methods, education and rehabilitation in conditions of total control. The treatment of such patients under strict security conditions is a very protracted process, and therefore patients often become incurable for some time, and even for ever. These "incurable psychopaths" can play a very negative role, disorganizing other patients in a particular ward and in the hospital as a whole.

Departments with enhanced security mode

Among patients placed in regional units with enhanced safety regimen, only a very small part as the main diagnosis is a psychopathic disorder. Most of these patients are transferred here from special hospitals - as an attempt to rehabilitate the patient in the community. Very few people come directly from the courts, prisons and the community. The therapeutic approach is the same as in the special hospital. Additional attention and strengthened control appear to be effective tools for reducing the level of behavioral disorders, at least in the institution itself.

[5], [6], [7], [8], [9], [10], [11], [12]

Henderson Hospital, England

This unit, located at the Belmont Hospital in Sutton, originated in 1947 to treat patients with a "psychopathic disorder" within the National Health System. Best of all, it works with well-expressed, intelligent and young enough psychopaths without a vast criminal or violent history. This unit is known for its approach - on the principle of a therapeutic community, developed under the leadership of Maxwell Jones. Hospital Henderson accepts only voluntary patients. She has 29 beds, and about half of her inmates have criminal convictions. According to the available research, at the moment the Henderson Hospital gives the best results for patients with "psychopathic disorders", although, of course, very high criteria for patient selection must be taken into account here.

Clinic Van der Hoeven, Utrecht, Holland

It is one of several well-known Dutch clinics that, under the guidance of psychiatrists, are engaged in the treatment of criminals suffering from psychopathic disorder. The private clinic Van der Hoeven is a therapeutic community (in a building with a physically adequate safety regime), which uses group psychotherapy in conjunction with rehabilitation and re-socialization training programs. This is supplemented by a good system of "parole" release. Prisoners are in the clinic for about two years. Although the clinic indicates its success in terms of both short-term and long-term changes in its clients, these allegations have not yet been confirmed in controlled studies.

[13], [14], [15], [16], [17], [18]

Organization of stay in dormitory probation services

Dormitory probation services differ in their ability to improve the behavior of probationers during their stay in the hostel. The study showed that the most effective were the hostels with an atmosphere of attention to its inhabitants, albeit with a strict schedule. The least effective were hostels with an atmosphere of permissiveness or indifference and a lack of interest in the inhabitants of the hostel. Unfortunately, those successes that are noted in the behavior of persons who are on probation during their stay in the hostel do not persist after leaving the community. After two or three years the level of relapses turned out to be the same, regardless of the characteristics of the hostel.

Individual psychotherapy in the community

The most famous work in this direction is the Cambridge-Somerville study, begun in the USA. It was an attempt to see how individual psychological counseling can prevent the development of an antisocial personality in young people at risk. In the course of the experiment, the treated and untreated groups were compared. It was assumed that young people from the treatment group would have to meet on a voluntary basis on a weekly basis with the same consultant. Unfortunately, the experiment was interrupted by the Second World War, and the consultants were taken into the army. In general, it can be said that people who received psychological counseling were not better than those who did not receive it.

Other individual clinical approaches

The questions of psychotherapy of persons with borderline and narcissistic personality disorders are covered in the review. The main conclusion from this study is the need for long-term adherence to treatment. Supporters of each method declare their success, but, nevertheless, without comparative tests it remains unclear which approach will be effective in each particular case.

Therapy is a reality

This is an attempt to teach delinquents practical social skills - how to solve real problems at the present time.

Supportive psychological counseling

This is the main support of probation and outpatient services. Perhaps the firmness, tactfully combined with the psychological acceptance of the client and the warm attitude towards him, is the most effective way, although there is no evidence that such an approach can provide lasting changes in the client. From a clinical point of view, the method helps them not to get into problems while they are involved in the counseling and support program.

Dynamic psychotherapy

There have been many individual statements about the successful use of dynamic psychotherapy, but there is no consistent evidence to support these methods. In principle, it is impossible to use dynamic psychotherapy with patients suffering from an antisocial personality disorder, although there are reports of some successes in a hospital setting. In general, dynamic psychotherapy is unsuitable for the treatment of patients isolated from society on the basis of psychopathic disorder.

[19], [20], [21], [22], [23], [24], [25], [26], [27]

Family therapy

This type of intervention will make it possible to expose the family dynamics and is a very powerful tool. Empirical studies of the effectiveness of this method in criminals with personality disorders do not.

[28], [29], [30], [31], [32]

Group therapy

Working in a group can be very useful, and it is usually used in institutions that contain individuals with personality disorders. Cognitive therapy

Among people who have problems with anger and violence, there has been some success in using psychological therapy based on the recognition of automatic thoughts combined with relaxation, as well as techniques for modifying cognition and behavior. In particular, there have been some successes in changing violent behavior, at least for a short period of time. This therapeutic approach will help in the treatment of certain specific aspects of behavior or attitudes in individual patients. The selection criteria are the same as for psychotherapy in "non-psychopathic" persons.

Methods of physical therapy

There have been attempts to treat "psychopaths" with the help of electroshock therapy, as well as psychosurgery. However, there is no reliable evidence of the effectiveness of both methods mentioned for this group of patients.

Drug treatment of psychopathic disorder

Personality disorders can not be cured by medicines, but medicines can provide some help, in particular to persons with severe symptoms of tension and anxiety. Careful use of drugs most often helps patients with borderline personality disorder. It seems that pharmacotherapy can help people with schizotypal personality disorder, as well as some personality disorders associated with loss of control over their own behavior. A very detailed review of the effects of pharmacotherapy on individuals included in the category of psychopathic disorder was prepared by Dr. Bridget Dolan (V. Dolan) and Dr. Jeremy Coid (J. Coid) for the report of the Working Group on Psychopathic Disorder under the leadership of Dr. Reed . Dolan and Coid published their results in a book published in 1993. These results are included in the brief information below.

[33], [34], [35], [36], [37], [38], [39]

Benzodiazepines

The existing literature on the effect of benzodiazepines on behavior and personality disorders is not of high quality. At the same time, as the clinical experience proves, benzodiazepines can be useful in acute situations of loss of control and with expressed violations of behavior on the part of the patient, or used for short-term admission during periods of anxiety and stress. However, caution is needed here, since there are reports that some react to benzodiazepines by disinhibition and furious reactions. In general, these drugs should not be used to treat personality disorders, in particular because of their high addictive potential.

[40], [41], [42], [43], [44], [45]

Antidepressants

Depression is an integral part of many personality disorders, and it usually fluctuates, regardless of the use of antidepressants. To date, there are no adequately performed studies that would prove that when taking antidepressants, the improvement in patients comes precisely as a result of the pharmacological action of the drug, and is not only a natural change in the present state. However, patients with personality disorders can develop very severe depression, and with severe depression it is important to use antidepressants. Stable dysphoria and atypical depression with borderline personality disorder may respond to MAO inhibitors. But, given the potential danger of the side effects of these drugs and the unreliability of patients with severe personality disorders, MAO inhibitors may be appropriate only after unsuccessful attempts to use lithium and carbamazepine.

Supportive therapy with lithium seems to be a promising direction in the treatment of personality disorders. Lithium is especially indicated for patients with personality disorders with impulsive manifestations, unstable moods or unintended aggressive outbreaks.

[46], [47], [48], [49], [50], [51], [52], [53], [54]

Large tranquilizers

To reduce the steady-state voltage, any of the larger tranquilizers can be used - sometimes they work even at relatively low doses (for example, flupenthixol 20 mg per month and less), but higher periods may require higher doses during periods of high voltage. Low-dose therapy can be particularly effective for patients with schizotypic features, as well as for individuals in whom psychopathic disorder occurs with recurrent, brief episodes. Neuroleptics also, in particular, help some patients with borderline personality disorder with self-harm, aggressive outbreaks and periods of anxiety and depersonalization.

Stimulants

It has long been noted that amphetamines can reduce the feeling of tension in some psychopaths, but here the danger of drug abuse and the development of drug dependence in general outweigh the possible benefits of taking amphetamines. Of great interest is the topic of using amphetamine mixtures in adults, who in childhood had a persistent attention deficit with hyperactivity. Many such adults in the United States are assigned derivatives of amphetamines, with a confirmed good effect. However, in the United Kingdom there is still considerable skepticism in this matter, and such appointments are very rare.

Anticonvulsants

It is proved that carbamazepine helps with hyperactivity, aggression and weakness of control over impulsive behavior. This effect is not limited to any individual personality disorders. Rather, it is symptom-specific, and therefore it is better to use such therapy against the symptom, and not at the diagnosis of a specific personality disorder.

[55], [56], [57], [58], [59], [60], [61]

Medico-legal aspects of psychopathic disorder

In connection with a psychopathic disorder, one important legal issue arises - the possibility of being placed in a hospital, compared with the sentences for community assistance or imprisonment. From time to time, in cases of murder, the use of defense on the basis of reduced liability is permitted, but such cases are rare. Psychopathic disorder does not lead to a conclusion about the inability to make statements in court and to participate in legal proceedings or the recognition of insanity. If there is no recommendation for hospitalization, then the establishment of a psychopathic disorder can be a double-edged sword for the accused: on the one hand, when sentencing, it can be interpreted as a mitigating factor, but on the other hand, a judge weighing the verdict for an "incurable psychopath" , may appoint him a longer than usual detention period to protect society.

For many years psychiatrists have been very cautious about giving recommendations for hospital treatment of "psychopaths". To a large extent this is due to the lack of confidence in the curability of the disorder, as well as the lack of necessary resources and the negative experience of taking the patient for treatment with subsequent establishment of its incurable. By accepting a patient who is or afterwards becomes incurable, the psychiatrist risks facing a dilemma: increased pressure on the discharge of a person that is dangerous to the community, on the one hand, or a transition to "preventive" long-term maintenance in the hospital ("preventive" in this case means preventing harm society, i.e., psychiatric care becomes in-conclusion). The latter option is especially likely if the patient hospitalized under Art. 37/41 of the Mental Health Act, is recognized or rendered incurable, since in those cases the Ministry of the Interior and the Mental Health Tribunal are extremely reluctant to authorize an extract. In order to avoid similar problems in the future, the report of the Group, led by Dr. Reed, suggested some recommendations that are now being implemented in practice and legislation.

To facilitate the solution of the problem of a more precise definition of curability, two ways are suggested. First, the Reed Report recommends that decisions regarding treatment should be made only on the basis of a multi-disciplinary evaluation. In the past, decisions were sometimes made only by doctors, although the qualitative assessment now rightly implies the involvement of other disciplines. Secondly, the Law on Crimes (sentences) of 1997 introduced changes in Art. 38 of the 1983 Mental Health Act. At present, a temporary hospitalization order of up to 12 months can be used, thus providing a longer period of time for assessing the patient's condition and trial use of different types of treatment, before making final recommendations to the court.

If curability is established, then a whole range of new opportunities opens up in the sentencing. The Law on Crimes (sentences) of 1997 supplemented the Mental Health Act with new articles 45A and 45B. These articles give the Royal courts authority when imposing punishment on the accused with psychopathic disorder in the form of imprisonment, add to him a referral to the hospital. In fact, at present, there are the following options for choice: if the psychiatrist is confident in the curability of the "psychopathic" criminal, then the court may be recommended to put this person in a hospital in accordance with Art. 37 and 37/41 of the 1983 Mental Health Act. If the psychiatrist considers the culprit incurable, then recommendations for hospitalization will not follow (although there may be a subsequent informal return to this issue after the conviction and re-examination of the possibility of hospitalization in accordance with article 49/49 of the 1983 Mental Health Act). A new "order for hospitalization" in accordance with Art. 45A (known among professionals as a "hybrid warrant") is used only in cases where a psychiatrist can say that a criminal may be curable. The hybrid warrant requires the doctor to recommend that the court use the hospitalization order (Article 37), and the judge can already decide on a "hybrid order" if desired (the doctor can only recommend a warrant of hospitalization, but not a hybrid order as such). The essence of this order is that the accused simultaneously receives hospitalization, as well as the sentence of a fixed or indeterminate duration of imprisonment. In this case, the accused will begin serving the sentence in the hospital, and eventually he can be discharged to the community directly from the hospital. However, if the accused becomes incurable or completes treatment before the expiration of the sentence, he can be transferred to prison to serve the remaining term and subsequent release from prison. Currently, this new authority is being tested by the mental health services and the Ministry of the Interior. Since October 1997, when this order was put into effect, and until September 1998 no decision was taken to apply hybrid orders.