Diagnostic criteria
To establish a diagnosis, domestic psychiatrists rely on three mandatory criteria (P.B. Gannushkin's triad):
- Totality: pathological traits encompass the entire personality structure and manifest absolutely in any life situations, not only in stressful ones.
- Relative stability: the condition remains unchanged throughout life. It neither progresses nor undergoes regression.
- Adaptation impairment: the severity of pathological behavior is so high that it leads to social, family, or professional maladaptation.
A fundamental psychological feature of the disorder is egosyntonicity (from Latin ego meaning "I" and Greek syntonia meaning "consonance"). The patient perceives their behavior as a natural part of themselves. Due to such "psychological blindness" and inadequate self-assessment, a person is incapable of learning from their own mistakes. That is why diagnostics must be based on the interpretation of committed actions, while psychological tests play an exclusively auxiliary role.
Physique and temperament: Kretschmer's theory
German psychiatrist E. Kretschmer described the psychophysiological constitution—the biological unity of external appearance, hormonal background, and nervous system properties. He identified four types, each characterized by a specific somatotype, temperament, and susceptibility to diseases:
- Pyknic (cyclothymic): smooth proportions, prominent abdomen, and fat layer. The disposition is open and good-natured, but with mood swings ranging from melancholy to elation. Predisposition to atherosclerosis, type 2 diabetes, hypertension, and manic-depressive psychosis.
- Asthenic or leptosomatic (schizothymic): thin bones, elongated proportions, long neck. Characterized by introversion, a tendency toward introspection and asceticism. More commonly suffer from peptic ulcer disease, tuberculosis, and schizophrenia. In W. Sheldon's concept, this type corresponds to cerebrotonia (dominance of ectodermal tissues).
- Athletic (epileptothymic): massive skeleton, developed muscles. Temperament is decisive and fearless, but stubborn, vindictive, and cruel. Prone to injuries, migraines, and epilepsy.
- Gracile (hysterothymic): infantile appearance, short stature. Character is infantile and egocentric. Feelings are superficial, with an acute need for attention. High risk of neuroses and sexual disharmonies.
Classification by origin and higher nervous activity features
Depending on etiology, personality disorders are divided into two groups:
- Nuclear (constitutional): arise due to hereditary factors and early organic damage. Patients are severely maladapted, and treatment requires biological methods (psychopharmacotherapy), as psychotherapy is largely ineffective.
- Marginal (pathohistorical/pathsetCharacter development): formed under the influence of improper upbringing and a destructive environment. Behavior can be regulated through strict control and persistent psychotherapy.
Russian practice also applies a division according to I.P. Pavlov (based on the ratio of excitation and inhibition processes). The circle of excitable psychopathies includes individuals with excessive, uncontrollable, and antisocial behavior—society suffers from them first and foremost. The circle of inhibited psychopathies includes individuals with restrictive behavior—they are passive, avoid difficulties, and become victims of their character without causing inconvenience to others.
Briefly: answers to topical questions
What clinical types of psychopathy are included in the excitable circle according to I.P. Pavlov?
The circle of excitable psychopathies according to I.P. Pavlov's classification includes six clinical types. These are:
- Explosive and epileptoid — clinical type of excitable psychopathies.
- Paranoid — clinical type of excitable psychopathies.
- Hysterical — clinical type of excitable psychopathies.
- Unstable — clinical type of excitable psychopathies.
- Expansive schizoids — clinical type of excitable psychopathies.
- Hyperthymic — clinical type of excitable psychopathies.
Patients of this circle are prone to socially disapproved actions, unrestrained, uncontrollable, and antisocial. They are characterized by excessive behavior, from which the surrounding society suffers first.
What types of specific personality disorders are distinguished under rubric F60 in ICD-10?
The cited sources mention the following personality disorders and corresponding ICD-10 codes:
- Paranoid personality disorder (paranoid psychopathy) — F60.0.
- Borderline personality disorder — F60.31.
- Anankastic (obsessive-compulsive) personality disorder — F60.5.
- Other specific personality disorders — F60.8; these include passive-aggressive, narcissistic, and untamed disorders.
- Unspecified personality disorder — F60.9.
Also mentioned is anxious (avoidant) personality disorder, however, its code is not specified in the provided fragments.
What variants of psychopathy dynamics are distinguished besides decompensation?
Besides decompensation, phases are distinguished in the dynamics of psychopathies.
- Phases — seasonal fluctuations in activity during psychopathies, representing spontaneous changes in the patient's state.
- Decompensations — adaptation breakdowns in various life situations (manifesting as reactive depression, alcoholism, substance abuse, or reactive paranoid states).
Unlike phases, decompensations are closely related to stress response, temperament, and upbringing conditions.
Which groups of psychotropic drugs are used to manage decompensation in personality disorders?
In cases of decompensation and related conditions, the following groups of psychotropic drugs are used:
- Antipsychotics (neuroleptics) — for heightened excitability, anxiety, confusion, psychomotor agitation, suspiciousness, distrust, and delusions of persecution.
- Antidepressants — for concomitant depression; sedative antidepressants may be used for reactive depression.
- Tranquilizers — as part of reactive depression treatment, concurrently with antidepressants, to reduce anxiety, hopelessness, and insomnia.
Gannushkin's triad of criteria is easily remembered by the mnemonic "SAS": S — Stability (condition does not progress), A — Adaptation impairment (problems in family and society), S — Totality (manifests always and everywhere).
Class and exam questions
Can a diagnosis of personality disorder be made based solely on test results?
No, this is unacceptable. Tests and questionnaires reflect only isolated traits and do not assess the actual degree of adaptation. A diagnosis is established exclusively based on observing the patient's actual behavior.
How does a personality disorder differ from psychosis and endogenous diseases?
Personality disorders never involve delusions, hallucinations, or clouding of consciousness. In addition, diseases such as schizophrenia or epilepsy develop independently of a person's initial character and break it, forming new traits.
What is the decompensation of psychopathy?
This is an adaptation breakdown occurring against the background of a personality disorder under various life stresses. Decompensation may manifest as reactive depression, alcoholism, substance abuse, or reactive paranoid states.
What else to study on this topic
- Clinical characteristics of extraversion and introversion
- Development of Kretschmer's ideas in William Sheldon's theory (viscerotonia and cerebrotonia)
- Detailed analysis of types of psychopathies in the excitable circle
- Detailed analysis of types of psychopathies in the inhibited circle
- Differential diagnosis with behavioral disorders in organic brain lesions
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