Organic personality disorder

Organic personality disorder occurs after certain types of brain injury. This may be a head injury, an infection such as encephalitis, or the result of a brain disease such as multiple sclerosis. Significant changes occur in a person's behavior. Often, the emotional sphere and the ability to control impulsive behavior are affected. Although changes can occur as a result of damage to any part of the brain, forensic psychiatrists are particularly interested in damage to the frontal part of the brain.

According to ICD-10 requirements, in order to diagnose an organic personality disorder, in addition to evidence of brain disease, injury, or dysfunction, two of the following six criteria must be present:

• decreased ability to persistently continue purposeful activity;
• affective instability;
• impairment of social judgment;
• suspiciousness or paranoid ideas;
• changes in the tempo and fluency of speech;
• altered sexual behavior.

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Organic personality disorder and behavior

The reason for forensic psychiatrists to pay attention to this condition is the absence of normal control mechanisms associated with it, increased egocentrism and loss of normal social sensitivity. People with a previously benevolent personality suddenly commit a crime that does not fit their character. Time proves the development of an organic cerebral condition in them. Most often, such a picture is observed with an injury to the anterior lobe of the brain. It is suggested that the most relevant aspect of frontal lobe damage for forensic psychiatry is associated with impaired executive control, which, in turn, is defined as the ability to plan and foresee the consequences of one's behavior. The behavioral characteristics of such subjects reflect the characteristics of their past personality and their emotional reaction to the loss of their abilities, as well as the insufficiency of the functioning of the brain.

Organic Personality Disorder and the Law

Organic personality disorder is accepted by the court as a mental illness. And the illness can be used as a mitigating circumstance and possibly as a basis for a decision to commit to treatment. Problems arise with individuals who have some degree of antisocial personality and who have also suffered brain injuries which exacerbate their antisocial attitudes and behaviour. Such a patient, because of his persistent antisocial attitude towards people and situations, his heightened impulsivity and indifference to consequences, may prove very difficult for ordinary psychiatric hospitals. The matter may also be complicated by the subject's anger and depression associated with the fact of the illness. There is a temptation to describe such a patient as a person with a psychopathic disorder who is refractory to treatment, in order to transfer him to the wards of the penal system. Although this may be an appropriate step in mild cases, in reality it reflects the lack of specialized psychiatric units capable of dealing with such a problem. It should be remembered that s. 37 of the Mental Health Act provides for the possibility of applying for a guardianship order. Such an order may be an appropriate measure if the offender complies with the supervision regime and if the specialized unit is able to provide him with outpatient care.

Case Description:

A 40-year-old man, who had previously held a responsible position in the civil service, developed multiple sclerosis in his early thirties. The disease, which initially manifested itself in a cerebral form, gradually progressed with very short periods of remission. Magnetic resonance spectroscopy showed areas of demyelination in both frontal areas. As a result, his personality changed significantly: he became sexually disinhibited and began making offensive remarks about female employees at work. The man was dismissed on medical grounds. He developed promiscuity: he approached women in the street with indecent sexual propositions. Several times, after women refused, he committed indecent attacks on them in the street. Irritability and aggressiveness also increased in him. Due to a conviction for a number of indecent attacks on women under Section 37/41 of the Mental Health Act 1983, he was placed in a special institution with a high security regime. The disease continued to progress over the next two years, during which time his attacks on female staff and other patients increased in frequency, leading to his eventual transfer to a special hospital.

In the early 1970s, a number of authors proposed the term "episodic dyscontrol syndrome". It was suggested that there is a group of individuals who do not suffer from epilepsy, brain damage or psychosis, but who behave aggressively due to an underlying organic personality disorder. In this case, aggressive behavior is the only symptom of this disorder. Most individuals diagnosed with this syndrome are men. They have a long history of aggressive behavior dating back to childhood, and often have an unfavorable family background. The only evidence in favor of this syndrome is that these individuals often have EEG abnormalities, especially in the temporal region. They also describe an aura similar to that characteristic of temporal epilepsy. It has been suggested that there is a functional abnormality of the nervous system that leads to increased aggressiveness. According to Lishman, this syndrome is on the border between 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 under the section of organic personality disorder in adults. There is insufficient evidence of underlying epilepsy, and it is possible to classify it separately as an organic brain disease, but, according to Lucas, it is not worth it.

Similar claims have been made about attention deficit hyperactivity disorder. According to ICD-10, this condition is recognized in children as hyperkinetic disorder of childhood and is defined as “general.” “General” means that the hyperactivity is present in all situations, i.e. not just at school or just at home. It has been suggested that the most severe forms of this condition result from minimal brain damage and may persist into adulthood and manifest as disorders involving impulsivity, irritability, lability, explosiveness, and violence. According to available data, 1/3 of these will develop antisocial disorder in childhood, and most of this group will become criminals in adulthood. In childhood, therapeutic effects can be achieved with stimulant medication.

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Organic psychoses

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

1. evidence of the presence of brain disease;
2. connection between disease and syndrome over time;
3. recovery from a mental disorder with effective treatment of its cause;
4. lack of evidence of another cause for the syndrome.

Organic personality disorder can be presented in both neurotic and

1. 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. The subject's behavior simply reflects the psychosis and its content, i.e. a paranoid state can be expressed in suspicious and hostile behavior.

Organic psychoses and law

Under the Mental Health Act, psychosis is clearly recognised as a mental illness and can therefore be grounds for referral for treatment, as well as considered as a mitigating factor, etc. If the illness occurs following a head injury or other trauma, there may also be grounds for financial compensation.

Organic personality disorder caused by psychoactive substances

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

1. Intoxication due to ingestion of excessive amounts of a substance with mood changes, motor changes, and changes in psychological functioning.
2. Idiosyncratic intoxication (in the Russian translation of ICD-10 "pathological intoxication" - translator's note), when obvious intoxication is caused by a very small dose of a substance, which is due to the individual characteristics of the reaction in a given person. Here, a wide variety of effects can be observed, including delirium and changes in the autonomic nervous system.
3. Withdrawal effects: A variety of effects that may occur when a person suddenly stops taking a drug to which they have become dependent. These may include delirium, changes in the autonomic nervous system, depression, anxiety, and tremors.
4. Mental illness. May be associated in various ways with the use of psychoactive substances, i.e. act as

• as a direct effect of a substance such as amphetamines and their derivatives, cocaine, lysergic acid diethylamide, or drugs such as steroids;
• as an effect of sudden withdrawal of a substance, for example paranoid psychosis after alcohol withdrawal;
• as an effect of chronic use of a substance, such as alcoholic dementia;
• as a precursor to relapse or worsening of symptoms in patients with schizophrenia, eg cannabis.

Intoxication

The Mental Health Act expressly excludes simple alcohol and drug abuse from the conditions covered by the Act. In general, if a person takes an illegal drug (including alcohol), he or she is held responsible for any actions taken while intoxicated by that drug. Disinhibition or amnesia due to the drug is not a defence. The exceptions are listed below - (1) to (4), with (1) and (3) relating to "involuntary intoxication" and may result in the suspect being acquitted.

A situation where a person is tricked into taking a substance without knowing it (hard to prove).

A situation in which the reaction to a substance is highly individual and unexpected - for example, severe intoxication after taking a very small amount of a substance. Thus, there have been claims of cases of "pathological intoxication" in some individuals after very small doses of alcohol, especially if they have a history of brain damage. In such cases, after taking a small amount of alcohol, there is a short-term outbreak of severe aggression in a state of complete disorientation or even psychosis followed by sleep and amnesia. This position has its supporters and opponents. This situation has not yet been fully resolved, but nevertheless, the defense on this basis has been used in court, especially when the clinical picture of an organic personality disorder is proven.

A situation where a person has an adverse reaction to a medication prescribed to them by a doctor. For example, the sedative effect of a medication can cause some people to have completely unusual reactions that are in no way related to their usual behavior. In this case, the actions may be performed by such a person unintentionally.

Edwards described the criteria for establishing a genuine connection between drug intoxication and the crime committed. Thus, there must be a clear connection between the drug and the act. The adverse reaction must be documented by a person authorized to do so; the action must not be a manifestation of the disease that the patient suffers from, and he must not have taken any other drugs that could cause a similar reaction; the drug intake and the reaction must be adequately related in time; and the reaction must disappear after stopping the drug.

A situation where the level of intoxication is such that the subject is no longer able to form an intent. Courts are very skeptical of a defense based on this ground, as they fear that a successful challenge could trigger a wave of similar claims from criminals who committed a crime while under the influence of alcohol. It is now established that a defendant will not be acquitted of crimes with an initial intent (such as manslaughter, assault, and unlawful wounding) if he, aware of the consequences of this step, voluntarily took alcohol or drugs and thereby deprived himself of the ability to control himself or ceased to be aware of his actions. In the case of crimes with a special intent (manslaughter or theft), the defense of "lack of intent" will remain. In the case of manslaughter, the charge may be reduced to manslaughter.

Quite often, people who were severely intoxicated at the time of the crime claim that they do not remember anything about the crime and that it was all "due to alcohol." An examination of the relevant statements almost always confirms that the subject's behavior is quite understandable in the given situation, regardless of the fact that he was drunk. In such cases, the defense based on the influence of intoxication is not allowed. At the same time, after sentencing, the courts often treat people who want to get rid of alcohol or drug addiction with sympathy and make decisions on probation with the condition of addiction treatment, if, of course, this is acceptable in the particular case and the crime committed is not very serious.

In some cases, the psychiatrist may be asked about the effect of alcohol taken while taking a drug on the person's mental state or degree of intoxication. Blood alcohol levels vary with the age of the subject, the type of drink (carbonated drinks are absorbed more quickly), the presence of food in the stomach, body composition, and the rate of emptying of the digestive tract (under the influence of some drugs). Euphoria is noted at 30 mg/100 ml, impaired driving at 50, dysarthria at 160 with possible loss of consciousness above this level, and death at levels above 400. At 80, the risk of a traffic accident is more than twice as high, and at 160, more than ten times as high. The rate of alcohol metabolism is approximately 15 mg/100 ml/hour, but there can be wide variation. Heavy drinkers have a higher rate of metabolism unless they have liver disease, which slows the metabolism. The Court of Appeal allowed the reverse calculation to be made from the known blood level and introduced into evidence. The psychiatrist may be asked to comment on factors that may have played a role in the case.

Withdrawal disorders

The court may accept as a mitigating factor the mental disorder caused by the cessation of the use of the substance - of course, in cases where there was no reason to expect such disorder on the part of the subject.

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Organic personality disorder associated with substance abuse

In cases where a crime is committed during a person's mental illness caused by a psychoactive substance, the courts are willing to consider this as a mitigating factor and, with a doctor's recommendation, to refer such persons for treatment, provided, of course, that such a referral seems fair and reasonable to them. On the other hand, psychiatrists are not always willing to recognize a person with a temporary disorder due to substance abuse as a patient, especially if the patient is known to have antisocial tendencies. The difficulty here is that in some persons mental illness is preceded by drug use, and the mental illness that manifests itself does not quickly resolve, but begins to acquire characteristics of a chronic psychosis (for example, schizophrenia), the treatment of which requires hospitalization and supportive care.