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Ministry of Health of Ukraine Bukovynian State Medical University

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Ministry of Health of Ukraine

Bukovynian State Medical University


on the methodical meeting

of the Department of neurology, psychiatry

and medical psychology nm. S.M.Savenko

“____” ___________ 2009 (Report № __).

Chief of the Department


Professor V.M. Pashkovsky


for 4-th year students of medical faculty №2

(the speciality “medical affair”)

for independent work during preparing to practical class

Theme 28: Mental retardation and delay of development. Psychopathies. Etiology, pathogenesis, clinical displays. Diagnostics and differential diagnostics. TREATMENT. Prophylaxis, question of expertise.

Psychopathies and pathological development of personality. Etiology and pathogenesis. Clinical forms of psychopathies. Diagnostics and differential diagnostics. TREATMENT. Question of expertise.


Topical module 6. Disorders of adult personality and behaviour. Mental retardation. Disorders of psychological development. Behavioural and emotional disorders with onset usually occurring in childhood and adolescence

Сhernivtsi, 2009

1. Actuality of theme:

Mental retardation affects about 1-3% of the population. There are many causes of mental retardation, but doctors find a specific reason in only 25% of cases.

MR/ID is not a specific medical disorder like pneumonia or strep throat, and it is not a mental health disorder. People with MR/ID have significantly below average intellectual functioning that limits their ability to cope with two or more activities of normal daily living (adaptive skills). These activities include the ability to communicate; live at home; take care of oneself, including making decisions; participate in leisure, social, school, and work activities; and be aware of personal health and safety.

People with MR/ID have varying degrees of impairment. While recognizing each person's individuality, doctors find it helpful to classify a person's level of functioning. Intellectual functioning levels can be based on the results of developmental quotient (DQ) tests and intelligence quotient (IQ) tests or on the level of support needed. Support is categorized as intermittent, limited, extensive, or pervasive. Intermittent means occasional support; limited means support such as a day program in a sheltered workshop; extensive means daily, ongoing support; and pervasive means a high level of support for all activities of daily living, possibly including full-time nursing care.

^ Personality disorders affect 10-15% of the adult population. Individuals may have more than one personality disorder. Patients with personality disorders are at higher risk than the general population for many psychiatric disorders. Mood disorders are a particular risk across all personality diagnoses. The following are prevalences for specific personality disorders in the general population:

  • Paranoid personality disorder - 0.5-2.5%

  • Schizotypal personality disorder - 3%

  • Antisocial personality disorder - 3% of men, 1% of women

  • Borderline personality disorder - 2%

  • Histrionic personality disorder - 2-3%

  • Narcissistic personality disorder - less than 1%

  • Avoidant personality disorder - 0.5-1%

  • Obsessive-compulsive personality disorder - 1%

2. Duration of practical classes - 2 hours.


3.1. To know:

  1. Etiology and pathogenesis of mental retardation and personality disorders.

  2. Classifications of mental retardation and personality disorders.

  3. The basic psychopathological syndromes of mental retardation.

  4. The clinical pictures of personality disorders.

  5. The diagnostic criteria of mental retardation and personality disorders: clinical, paraclinical, psychological and social.

  6. Treatment of patients with mental retardation and personality disorders.

  7. Prophylactic of mental retardation and personality disorders.

  8. Expertise of patients with mental retardation and personality disorders.

3.2. Able:

1.To diagnose mental retardation and personality disorders.

2. To conduct differential diagnosis to other mental disease.

3.To give first aid about excitement of patients with mental retardation and personality disorders.

4.To conduct measures of prophylactic of mental retardation and personality disorders.

3.3. To capture practical skills:

1.To collect anamnesis in patients with mental retardation and personality disorders.

2.To conduct clinical psychopathological examination of patients with mental retardation and personality disorders.

3. To give first aid about excitement of patients with mental retardation and personality disorders.

^ 4. INTERSUBJECT INTEGRATION (base level of preparation).

Names of previous disciplines

Skills are got

1. Medical genetic.

2. Normal and pathologic physiology.

3. Anatomy

4. Medical psychology

1.To possess of methods examination genetic diseases of human.

2. To know functions of brain, physiology and pathological physiology HNA.

3. To know structure of brain

4. To know psychology of personality.

5. Advices to students.


Mental retardation

A condition of arrested or incomplete development of the mind, which is especially characterized by impairment of skills manifested during the developmental period, skills which contribute to the overall level of intelligence, i.e. cognitive, language, motor, and social abilities. Retardation can occur with or without any other mental or physical condition.

Degrees of mental retardation are conventionally estimated by standardized intelligence tests. These can be supplemented by scales assessing social adaptation in a given environment. These measures provide an approximate indication of the degree of mental retardation. The diagnosis will also depend on the overall assessment of intellectual functioning by a skilled diagnostician.

Intellectual abilities and social adaptation may change over time, and, however poor, may improve as a result of training and rehabilitation. Diagnosis should be based on the current levels of functioning.

The following fourth-character subdivisions are for use with categories F70-F79 to identify the extent of impairment of behaviour:


With the statement of no, or minimal, impairment of behaviour


^ Significant impairment of behaviour requiring attention or treatment


Other impairments of behaviour


Without mention of impairment of behaviour

Use additional code, if desired, to identify associated conditions such as autism, other developmental disorders, epilepsy, conduct disorders, or severe physical handicap.


Mild mental retardation

Approximate IQ range of 50 to 69 (in adults, mental age from 9 to under 12 years). Likely to result in some learning difficulties in school. Many adults will be able to work and maintain good social relationships and contribute to society.


Moderate mental retardation

Approximate IQ range of 35 to 49 (in adults, mental age from 6 to under 9 years). Likely to result in marked developmental delays in childhood but most can learn to develop some degree of independence in self-care and acquire adequate communication and academic skills. Adults will need varying degrees of support to live and work in the community.


Severe mental retardation

Approximate IQ range of 20 to 34 (in adults, mental age from 3 to under 6 years). Likely to result in continuous need of support.


Profound mental retardation

IQ under 20 (in adults, mental age below 3 years). Results in severe limitation in self-care, continence, communication and mobility.

^ Levels of Mental Retardation/Intellectual Disability


Intelligence Quotient (IQ) Range

Ability at Preschool Age (Birth to 6 Years)

Ability at School Age (6 to 20 Years)

Ability at Adult Age (21 Years and Older)



Can develop social and communication skills; motor coordination is slightly impaired; often not diagnosed until later age

Can learn up to about the 6th-grade level by late teens; can be expected to learn appropriate social skills

Can usually achieve enough social and vocational skills for self-support; may need guidance and assistance during times of unusual social or economic stress



Can talk or learn to communicate; social awareness is poor; motor coordination is fair; can profit from training in self-help

Can learn some social and occupational skills; can progress to elementary school level in schoolwork; may learn to travel alone in familiar places

May achieve self-support by performing unskilled or semiskilled work under sheltered conditions; needs supervision and guidance when under mild social or economic stress



Can say a few words; able to learn some self-help skills; has limited speech skills; motor coordination is poor

Can talk or learn to communicate; can learn simple health habits; benefits from habit training

May contribute partially to self-care under complete supervision; can develop some useful self-protection skills in controlled environment


19 or below

Extreme cognitive limitation; little motor coordination; may need nursing care

Some motor coordination; limited communication skills

May achieve very limited self-care; usually needs nursing care

Causes A wide variety of medical and environmental conditions can cause MR/ID. Some are genetic; some are present before or at the time of conception; and others occur during pregnancy, during birth, or after birth. The common factor is that something interferes with the growth and development of the brain. However, doctors can identify a specific cause in only about one third of people with mild MR/ID and in two thirds of people with moderate to profound MR/ID.

Some Causes of Mental Retardation/Intellectual Disability

  • Before or At Conception

    • Inherited disorders (such as phenylketonuria, Tay-Sachs disease, neurofibromatosis, hypothyroidism, and fragile X syndrome)

    • Chromosome abnormalities (such as Down syndrome)

  • During Pregnancy

    • Severe maternal malnutrition

    • Infections with HIV, cytomegalovirus, herpes simplex, toxoplasmosis, rubella virus

    • Toxins (such as alcohol, lead, and methylmercury)

    • Drugs (such as phenytoin, valproate, isotretinoin, and cancer chemotherapy)

    • Abnormal brain development (such as porencephalic cyst, grey matter heterotopia, and encephalocele)

    • Preeclampsia and multiple births

  • During Birth

    • Insufficient oxygen (hypoxia)

    • Extreme prematurity

  • After Birth

    • Brain infections (such as meningitis and encephalitis)

    • Severe head injury

    • Malnutrition of the child

    • Severe emotional neglect or abuse

    • Toxins (such as lead and mercury)

    • Brain tumors and their treatments


Some children with MR/ID have abnormalities apparent at birth or shortly thereafter. These abnormalities may be physical as well as neurologic and may include unusual facial features, a head that is too large or too small, deformities of the hands or feet, and various other abnormalities. Sometimes children have an outwardly normal appearance but have other signs of serious illness, such as seizures, lethargy, vomiting, abnormal urine odor, and failure to feed and grow normally. During their first year, many children with more severe MR/ID have delayed development of motor skills, and are slow to roll, sit, and stand.

However, most children with MR/ID do not develop symptoms that are noticeable until the preschool period. Symptoms become apparent at a younger age in those more severely affected. Usually, the first problem parents notice is a delay in language development. Children with MR/ID are slower to use words, put words together, and speak in complete sentences. Their social development is sometimes slow, because of cognitive impairment and language deficiencies. Children with MR/ID may be slow to learn to dress and feed themselves. Some parents may not consider the possibility of cognitive impairment until the child is in school or preschool and is unable to keep up with age-appropriate expectations.

Children with MR/ID are somewhat more likely than other children to have behavioral problems, such as explosive outbursts, temper tantrums, and physically aggressive behavior. These behaviors are often related to specific frustrating situations compounded by an impaired ability to communicate and control impulses. Older children may be gullible and easily taken advantage of or led into minor misbehavior.

About 10 to 40% of people with MR/ID also have a mental health disorder (dual diagnosis). In particular, anxiety and depression are common, especially in children who are aware that they are different from their peers or who are maligned and mistreated because of their disability.


Many children are evaluated by teams of professionals, including a pediatric neurologist or developmental pediatrician, a psychologist, speech pathologist, occupational or physical therapist, special educator, social worker, or nurse.

Doctors evaluate a child suspected of having MR/ID by testing intellectual functioning and looking for a cause. Even though the cause of the child's MR/ID may be irreversible, identifying a disorder that caused the disability may allow doctors to predict the child's future course, prevent further loss of skills, plan any interventions that can increase the child's level of functioning, and counsel parents on the risk of having another child with that disorder.

Newborns with physical abnormalities or other symptoms suggestive of a condition associated with MR/ID often need laboratory tests to help detect metabolic and genetic disorders. Imaging tests, such as computed tomography (CT) or magnetic resonance imaging (MRI), may be performed to look for structural problems within the brain. An electroencephalogram (EEG) records the brain's electrical activity and is used to evaluate a child for possible seizures. A chromosome analysis, urine and blood tests, and x-rays of bones can also help rule out suspected causes of MR/ID.

Some children who are delayed in learning language and mastering social skills have conditions other than MR/ID. Because hearing problems interfere with language and social development, a hearing evaluation is typically performed. Emotional problems and learning disorders also can be mistaken for MR/ID. Children who have been severely deprived of normal love and attention for long periods of time may seem to have MR/ID. A child with delays in sitting or walking (gross motor skills) or in manipulating objects (fine motor skills) may have a neurologic disorder not associated with MR/ID.

Because mild developmental problems are not always noticed by parents, doctors routinely perform developmental screening tests during well-child visits. Doctors use simple questionnaires, such as the Ages and Stages Questionnaires or Child Development Inventories, to quickly evaluate the child's cognitive, verbal, and motor skills. Parents can help the doctor determine the child's level of functioning by completing a Parents' Evaluation of Developmental Status (PEDS) test. Children who perform significantly below their age level on these screening tests are referred for formal testing.

Formal testing has three components: interviews with parents, observations of the child, and norm-referenced tests. Some tests, such as the Stanford-Binet Intelligence Test and the Wechsler Intelligence Scale for Children-IV (WISC-IV), measure intellectual ability. Other tests, such as the Vineland Adaptive Behavior Scales, assess areas such as communication, daily living skills, social abilities, and motor skills. Generally, these formal tests accurately compare a child's intellectual and social abilities with those of others in the same age group. However, children of different cultural backgrounds, non–English-speaking families, and very low socioeconomic status are more likely to perform poorly on these tests. For these reasons, a diagnosis of MR/ID requires that the doctor integrate the test data with information obtained from parents and direct observations of the child. A diagnosis of MR/ID is appropriate only when both intellectual and adaptive skills are significantly below average.

^ Prevention and Prognosis

Prevention applies to environmental, genetic, and infectious disorders as well as to accidental injuries. Fetal alcohol syndrome is a highly common and totally preventable cause of MR/ID. The March of Dimes and other groups concerned about the prevention of MR/ID focus much of their efforts on alerting women to the seriously damaging effects of drinking alcohol during pregnancy. Doctors may recommend genetic testing for people who have a family member or other child with a known inherited disorder, particularly ones related to MR/ID, such as phenylketonuria, Tay-Sachs disease, or fragile X syndrome. Identification of a gene for an inherited disorder allows genetic counselors to help parents evaluate the risk of having an affected child. Women who plan to get pregnant should receive necessary vaccinations, particularly against rubella. Women who are at risk for infectious disorders that may be harmful to a fetus, such as rubella and human immunodeficiency virus (HIV), should be tested before getting pregnant.

Proper prenatal care lowers the risk of having a child with MR/ID. Folic acid, a vitamin supplement, taken before conception and early in pregnancy can help prevent certain kinds of brain abnormalities. Advances in the practices of labor and delivery and in the care of premature infants have helped to reduce the rate of MR/ID related to prematurity.

Certain tests, such as ultrasound, amniocentesis, chorionic villus sampling, and various blood tests, can be performed during pregnancy to identify conditions that often result in MR/ID. Amniocentesis or chorionic villus sampling is often used for women at high risk of having a baby with Down syndrome, especially those aged 35 and older, and for women with family histories of metabolic disorders. Maternal serum alpha-fetoprotein is a helpful screen for neural tube defects, Down syndrome, and other abnormalities. A few conditions, such as hydrocephalus and severe Rh incompatibility, may be treated during pregnancy. Most conditions, however, cannot be treated, and early recognition can serve only to prepare the parents and allow them to consider the option of abortion.

Because MR/ID sometimes coexists with serious physical problems, the life expectancy of children with MR/ID may be shortened, depending on the specific condition. In general, the more severe the cognitive disability and the more physical problems the child has, the shorter the life expectancy. However, a child with mild MR/ID has a relatively normal life expectancy, and health care is improving long-term health outcomes for people with all types of developmental disabilities. Many people with mild to moderate MR/ID can support themselves, can live independently, and can be successful at jobs that require basic intellectual skills.


A child with MR/ID is best cared for by a multidisciplinary team consisting of the primary care doctor; social workers; speech, occupational, and physical therapists; neurologists or developmental pediatricians; psychologists; nutritionists; educators; and others. Together with the family, these people develop a comprehensive, individualized program for the child, which is begun as soon as the diagnosis of MR/ID is suspected. The parents and siblings of the child also need emotional support and sometimes counseling. The whole family should be an integral part of the program.

The full array of a child's strengths and weaknesses must be considered in determining what kind of support is needed. Factors such as physical disabilities, personality problems, mental illness, and interpersonal skills are all taken into consideration. Affected children with coexisting mental health disorders such as depression may be given appropriate drugs in dosages similar to those given to children without MR/ID. However, giving a child drugs without also instituting behavioral therapy and environmental changes is usually not helpful.

All children with MR/ID benefit from special education. The federal Individuals with Disabilities Education Act (IDEA) requires public schools to provide free and appropriate education to children and adolescents with MR/ID or other developmental disorders. Education must be provided in the least restrictive, most inclusive setting possible–where the children have every opportunity to interact with non-disabled peers and have equal access to community resources.

A child with MR/ID usually does best living at home. However, some families cannot provide care at home, especially for children with severe, complex disabilities. This decision is difficult and requires extensive discussion between the family and their entire support team. Having a child with severe disabilities at home requires dedicated care that some parents may not be able to provide. The family may need psychologic support. A social worker can organize services to assist the family. Help can be provided by day care centers, housekeepers, child caregivers, and respite care facilities. Most adults with MR/ID live in community-based residences that provide services appropriate to the person's needs, as well as work and recreational opportunities.

^ Disorders of adult personality and behaviour
This block includes a variety of conditions and behaviour patterns of clinical significance which tend to be persistent and appear to be the expression of the individual's characteristic lifestyle and mode of relating to himself or herself and others. Some of these conditions and patterns of behaviour emerge early in the course of individual development, as a result of both constitutional factors and social experience, while others are acquired later in life. Specific personality disorders (F60.-), mixed and other personality disorders (F61.-), and enduring personality changes (F62.-) are deeply ingrained and enduring behaviour patterns, manifesting as inflexible responses to a broad range of personal and social situations. They represent extreme or significant deviations from the way in which the average individual in a given culture perceives, thinks, feels and, particularly, relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems of social performance.


Specific personality disorders

These are severe disturbances in the personality and behavioural tendencies of the individual; not directly resulting from disease, damage, or other insult to the brain, or from another psychiatric disorder; usually involving several areas of the personality; nearly always associated with considerable personal distress and social disruption; and usually manifest since childhood or adolescence and continuing throughout adulthood.


Paranoid personality disorder

Personality disorder characterized by excessive sensitivity to setbacks, unforgiveness of insults; suspiciousness and a tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous; recurrent suspicions, without justification, regarding the sexual fidelity of the spouse or sexual partner; and a combative and tenacious sense of personal rights. There may be excessive self-importance, and there is often excessive self-reference.


Schizoid personality disorder

Personality disorder characterized by withdrawal from affectional, social and other contacts with preference for fantasy, solitary activities, and introspection. There is a limited capacity to express feelings and to experience pleasure.


Dissocial personality disorder

Personality disorder characterized by disregard for social obligations, and callous unconcern for the feelings of others. There is gross disparity between behaviour and the prevailing social norms. Behaviour is not readily modifiable by adverse experience, including punishment. There is a low tolerance to frustration and a low threshold for discharge of aggression, including violence; there is a tendency to blame others, or to offer plausible rationalizations for the behaviour bringing the patient into conflict with society.


Emotionally unstable personality disorder

Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.


Histrionic personality disorder

Personality disorder characterized by shallow and labile affectivity, self-dramatization, theatricality, exaggerated expression of emotions, suggestibility, egocentricity, self-indulgence, lack of consideration for others, easily hurt feelings, and continuous seeking for appreciation, excitement and attention.


Anankastic personality disorder

Personality disorder characterized by feelings of doubt, perfectionism, excessive conscientiousness, checking and preoccupation with details, stubbornness, caution, and rigidity. There may be insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive-compulsive disorder.


Anxious [avoidant] personality disorder

Personality disorder characterized by feelings of tension and apprehension, insecurity and inferiority. There is a continuous yearning to be liked and accepted, a hypersensitivity to rejection and criticism with restricted personal attachments, and a tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.


Dependent personality disorder

Personality disorder characterized by pervasive passive reliance on other people to make one's major and minor life decisions, great fear of abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others, and a weak response to the demands of daily life. Lack of vigour may show itself in the intellectual or emotional spheres; there is often a tendency to transfer responsibility to others.


Mixed and other personality disorders

This category is intended for personality disorders that are often troublesome but do not demonstrate the specific pattern of symptoms that characterize the disorders described in F60.-. As a result they are often more difficult to diagnose than the disorders in F60.-.

Examples include:

  • mixed personality disorders with features of several of the disorders in F60.- but without a predominant set of symptoms that would allow a more specific diagnosis

  • troublesome personality changes, not classifiable to F60.- or F62.-, and regarded as secondary to a main diagnosis of a coexisting affective or anxiety disorder.


Enduring personality changes, not attributable to brain damage and disease

Disorders of adult personality and behaviour that have developed in persons with no previous personality disorder following exposure to catastrophic or excessive prolonged stress, or following a severe psychiatric illness. These diagnoses should be made only when there is evidence of a definite and enduring change in a person's pattern of perceiving, relating to, or thinking about the environment and himself or herself. The personality change should be significant and be associated with inflexible and maladaptive behaviour not present before the pathogenic experience. The change should not be a direct manifestation of another mental disorder or a residual symptom of any antecedent mental disorder.


Enduring personality change after catastrophic experience

Enduring personality change, present for at least two years, following exposure to catastrophic stress. The stress must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality. The disorder is characterized by a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and estrangement. Post-traumatic stress disorder (F43.1) may precede this type of personality change.


Enduring personality change after psychiatric illness

Personality change, persisting for at least two years, attributable to the traumatic experience of suffering from a severe psychiatric illness. The change cannot be explained by a previous personality disorder and should be differentiated from residual schizophrenia and other states of incomplete recovery from an antecedent mental disorder. This disorder is characterized by an excessive dependence on and a demanding attitude towards others; conviction of being changed or stigmatized by the illness, leading to an inability to form and maintain close and confiding personal relationships and to social iso-lation; passivity, reduced interests, and diminished involvement in leisure activities; persistent complaints of being ill, which may be associated with hypochondriacal claims and illness behaviour; dysphoric or labile mood, not due to the presence of a current mental disorder or antecedent mental disorder with residual affective symptoms; and longstanding problems in social and occupational functioning.


Habit and impulse disorders

This category includes certain disorders of behaviour that are not classifiable under other categories. They are characterized by repeated acts that have no clear rational motivation, cannot be controlled, and generally harm the patient's own interests and those of other people. The patient reports that the behaviour is associated with impulses to action. The cause of these disorders is not understood and they are grouped together because of broad descriptive similarities, not because they are known to share any other important features.


Pathological gambling

The disorder consists of frequent, repeated episodes of gambling that dominate the patient's life to the detriment of social, occupational, material, and family values and commitments.


Pathological fire-setting [pyromania]

Disorder characterized by multiple acts of, or attempts at, setting fire to property or other objects, without apparent motive, and by a persistent preoccupation with subjects related to fire and burning. This behaviour is often associated with feelings of increasing tension before the act, and intense excitement immediately afterwards.


Pathological stealing [kleptomania]

Disorder characterized by repeated failure to resist impulses to steal objects that are not acquired for personal use or monetary gain. The objects may instead be discarded, given away, or hoarded. This behaviour is usually accompanied by an increasing sense of tension before, and a sense of gratification during and immediately after, the act.



A disorder characterized by noticeable hair-loss due to a recurrent failure to resist impulses to pull out hairs. The hair-pulling is usually preceded by mounting tension and is followed by a sense of relief or gratification. This diagnosis should not be made if there is a pre-existing inflammation of the skin, or if the hair-pulling is in response to a delusion or a hallucination.


Gender identity disorders



A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex.


Dual-role transvestism

The wearing of clothes of the opposite sex for part of the individual's existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing.


Gender identity disorder of childhood

A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.-.


Disorders of sexual preference



Reliance on some non-living object as a stimulus for sexual arousal and sexual gratification. Many fetishes are extensions of the human body, such as articles of clothing or footwear. Other common examples are characterized by some particular texture such as rubber, plastic or leather. Fetish objects vary in their importance to the individual. In some cases they simply serve to enhance sexual excitement achieved in ordinary ways (e.g. having the partner wear a particular garment).


Fetishistic transvestism

The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create the appearance of a person of the opposite sex. Fetishistic transvestism is distinguished from transsexual transvestism by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. It can occur as an earlier phase in the development of transsexualism.



A recurrent or persistent tendency to expose the genitalia to strangers (usually of the opposite sex) or to people in public places, without inviting or intending closer contact. There is usually, but not invariably, sexual excitement at the time of the exposure and the act is commonly followed by masturbation.



A recurrent or persistent tendency to look at people engaging in sexual or intimate behaviour such as undressing. This is carried out without the observed people being aware, and usually leads to sexual excitement and masturbation.



A sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age.



A preference for sexual activity which involves the infliction of pain or humiliation, or bondage. If the subject prefers to be the recipient of such stimulation this is called masochism; if the provider, sadism. Often an individual obtains sexual excitement from both sadistic and masochistic activities.


Multiple disorders of sexual preference

Sometimes more than one abnormal sexual preference occurs in one person and there is none of first rank. The most common combination is fetishism, transvestism and sadomasochism.


Psychotherapy is at the core of care for personality disorders. Because personality disorders produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve perceptions of and responses to social and environmental stressors.

  • Psychodynamic psychotherapy examines the ways that patients perceive events, based on the assumption that perceptions are shaped by early life experiences. Psychotherapy aims to identify perceptual distortions and their historical sources and to facilitate the development of more adaptive modes of perception and response. Treatment is usually extended over a course of several years at a frequency from several times a week to once a month; it makes use of transference.

  • Cognitive therapy (also called cognitive behavior therapy [CBT]) is based on the idea that cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events. It deals with how people think about their world and their perception of it. This very active form of therapy identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviors. This therapy is typically limited to episodes of 6-20 weeks, once weekly. In the case of personality disorders, episodes of therapy are repeated often over the course of years.

  • Interpersonal therapy (IPT) conceives of patients' difficulties resulting from a limited range of interpersonal problems including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations, and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6-20 sessions. Though empirically validated for anxiety and depression, IPT is not widely practiced, and therapists conversant in the technique are difficult to locate.8

  • Group psychotherapy allows interpersonal psychopathology to display itself among peer patients, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behavior. Sessions are usually once weekly over a course that may range from several months to years.

  • Dialectical behavior therapy (DBT): This is a skills-based therapy (developed by Marsha Linehan, PhD) that can be used in both individual and group formats. It has been applied to borderline personality disorder. The emphasis of this manual-based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior. This treatment is also being used with other cluster B personality disorders to reduce impulsive behavior.


Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.

The focus is on treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol. These symptoms may complicate almost all personality disorders to varying degrees, but all of them have been noted in borderline personality disorder.

The assumption is that neurotransmitter abnormalities underlie these symptom clusters that transcend the concepts of Axis I and Axis II disorders. The strongest evidence for pharmacologic treatment of personality disorders has been for borderline personality disorder, but even this is based on a fairly small database of studies.


Because of overdose risk, tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) are usually not prescribed for patients with personality disorders. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are safe and reasonably effective. However, because the depression of most patients with personality disorders stems from their limited range of coping capacities, antidepressants are usually less effective than in patients with uncomplicated major depression. Antidepressants are most often prescribed for a limited time in patients with serious depressive episodes lasting longer than a few weeks.


Useful in stabilizing the affective extremes in patients with bipolar disorder but are less effective for that purpose in patients with personality disorders. They have some demonstrated efficacy in suppressing impulsive and particularly aggressive behavior in patients with personality disorder


Some personality disorders produce transient psychotic periods (especially borderline personality disorder), while others (eg, schizotypal personality disorder) feature chronic idiosyncratic ideation of nearly psychotic proportions.

Response to antipsychotics is less dramatic than in true psychotic Axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced. Antipsychotics are typically used for a short time while the symptoms are active.

The atypical antipsychotics have almost completely replaced the traditional neuroleptics because of their safety margin, but neurologic risks (including tardive dyskinesia and neuroleptic malignant syndrome) are never absent. Risperidone and olanzapine are described here; however, quetiapine and ziprasidone may also be used. No evidence indicates that any of these has superior efficacy, and each one may have advantages and disadvantages from the standpoint of adverse effects.


Within the limits of contemporary medical knowledge, personality disorders cannot be prevented, although steps can be taken to prevent or deter some of the consequences and complications of personality disorders.

    • Frequent inquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject. The physician need not fear instilling the idea of suicide in a patient who is not already entertaining it. Subsequent inquiry about firearms, lethal medications, and other available means of suicide point to avenues of preventive behavior.

    • Benzodiazepines, narcotic analgesics, and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders are marked by impaired impulse control and consequent risk of addictive behavior.

    • Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Their low frustration tolerance, externalization of blame for psychological distress, and impaired impulse control put the children of these patients at risk for neglect or abuse.

^ 5.2. Theoretic QUESTIONS:

  1. The definition of mental retardation and personality disorders.

  2. Etiology and pathogenesis of mental retardation and personality disorders.

  3. Classifications of mental retardation and personality disorders.

  4. The diagnostic criteria of mental retardation: clinical, paraclinical, psychological and social and different types of personality disorders.

  5. The types of dementia and its clinical peculiarities.

  6. Treatment of patients with mental retardation and personality disorders.

  7. Rehabilitation and social adaptation of patients with mental retardation and personality disorders.

  8. Prophylactic of mental retardation and personality disorders.

  9. Expertise of patients with mental retardation and personality disorders.

^ 5.3. Practical tasks on the class:

1. To collect anamnesis, clinical psychopathological examination of patients with mental retardation and personality disorders.

2. To diagnose different types of mental retardation and personality disorders.

3. The interpretation of results paraclinical methods examinations.

4. To solve the tasks and tests.

5.4. Material for self-contrrol.

A. Questions of self-controls:

  1. The definition of mental retardation and personality disorders.

  2. Etiology and pathogenesis of mental retardation and personality disorders.

  3. Classifications of mental retardation and personality disorders.

  4. The diagnostic criteria of mental retardation: clinical, paraclinical, psychological and social and different types of personality disorders.

  5. The types of dementia and its clinical peculiarities.

  6. Treatment of patients with mental retardation and personality disorders.

  7. Rehabilitation and social adaptation of patients with mental retardation and personality disorders.

  8. Prophylactic and expertise of patients with mental retardation and personality disorders.


1.IQ of mild mental retardation is:

A. 70-81

B. 50-69

C. 35-49

D. 34-20

E. below 20

2. IQ of moderate mental retardation is:

A. 70-81

B. 50-69

C. 35-49

D. 34-20

E. below 20

3. IQ of severe mental retardation is:

A. 70-81

B. 50-69

C. 35-49

D. 34-20

E. below 20

4. IQ of profound mental retardation is:

A. 70-81

B. 50-69

C. 35-49

D. 34-20

E. below 20

5.What psychopathy (personality disoders) is characterized by next signs - stiffness and circumstantial of thinking, inertness of psychical processes:

A.Epileptoid psychopathy

B. Paranoid psychopathy

C. Excitable psychopathy

D. Shisoid psychopathy

E. Hysteric psychopathy

6. What psychopathy (personality disoders) is characterized by next signs – emotionally cold, self-sufficient, detached, insensitiveness:

A.Epileptoid psychopathy

B. Hysteric psychopathy

C. Shisoid psychopathy

D. Excitable psychopathy

E. Paranoic psychopathy

7. What psychopathy (personality disoders) is characterized by next signs – emotionality, brightness of behaviour, egocentrism, demonstrativeness:

A.Epileptoid psychopathy

B. Excitable psychopathy

C. Shisoid psychopathy

D. Hysteric psychopathy

E. Paranoid psychopathy

8. What psychopathy (personality disoders) is characterized by next signs – inhibiting perfectionism, immersion in detail, indecisiveness:

A.Epileptoid psychopathy

B. Obsessional psychopathy

C. Shisoid psychopathy

D. Hysteric psychopathy

E. Paranoid psychopathy

9. What psychopathy (personality disoders) is characterized by next signs – sensitiveness, suspiciousness, irritability, touchiness, stubborness:

A.Epileptoid psychopathy

B. Obsessional psychopathy

C. Shisoid psychopathy

D. Hysteric psychopathy

E. Paranoid psychopathy

10. What psychopathy (personality disoders) is characterized by next signs – disregard for social obligations, low tolerance to frustration, a tendency to blame others:

A.Epileptoid psychopathy

B. Obsessional psychopathy

C. Shisoid psychopathy

D. Dissocial psychopathy

E. Paranoid psychopathy


6.1. Basic:

  1. Clinical Psychiatry from Synopsis of Psychiatry by H.I.Kaplan, B.J.Sadock. – New York: Williams @ Wilkins. – 1997.

  2. Psychiatry.Course of lectures.–Odessa: The Odessa State Medical University.–2005.–336 p.

  3. Lectures.

  4. Internet resource.

6.2. Additional:

  1. Морозов Т.В., Шумский Н.Г. Введение в клиническую психиатрию. – Н.Новгород: Изд-во НГМА, 1998.

  2. Попов Ю.В., Вид В.Д. Современная клиническая психиатрия. – М., 1997.

  3. Сонник Г.Т. Психіатрія: Підручник / Г.Т.Сонник, О.К.Напрєєнко, А.М.Скрипніков. – К.: Здоров’я, 2006.  


Prepared by assistant S.D.Savka


Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of health of ukraine bukovynian state medical university

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of health of ukraine bukovynian state medical university

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

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