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Mental health professionals can experience difficulties assessing people with personality disorders because of their own emotional reactions and stigma. But mental health professionals can improve their examinations of this population through better preparation.
Professionals should reflect on their own reactions and be honest about how they feel about people with personality disorders and how that feeling might compromise their examination, says Dr. Elias Abdalla-Filho in a presentation for the International Forensic Psychiatry Lecture Series. He is a former coordinator He is a former coordinator of the forensic psychiatry department of the Brazilian Psychiatric Association. Currently, he co-chairs the Forensic Psychiatry Section of the World Psychiatric Association.
Emotional Reactions
Mental health professionals often dislike assessing and treating people with personality disorders, who may behave in a manipulative, attention-seeking, or annoying manner. Such feelings may affect the professional’s ability to examine these patients objectively.
Dr. Abdalla-Filho has recognized his own feelings of helplessness when trying to treat a patient with a personality disorder with antisocial characteristics. On another occasion, when Dr. Abdalla-Filho invited residents to observe a forensic assessment of a person with a personality disorder, a resident was outraged by the examinee’s behaviour and reacted inappropriately.
One study of professionals’ interactions with people with personality disorders showed that professionals are more likely to have a lack of purpose when working with this population.
Stigma
In another study, clinicians said patients diagnosed with a personality disorder were more difficult to manage. But the clinicians did not have the same reaction to patients without the diagnoses but who, in fact, did have a personality disorder. This suggests that a diagnosis of personality disorder is stigmatizing.
Dr. Abdalla-Filho stresses that mental health professionals must remember that patients with a personality disorder have a mental disorder, even though they may act like a person without this mental condition.
Forensic Assessment
Forensic assessment of this population should include their ability to understand their actions (cognitive ability) as well as whether they can control their behaviour (volitional ability). Mental health professionals should consider both when examining criminal responsibility. But in many countries, even developed ones, mental health professionals do not assess volitional ability.
For example, a person with a personality disorder with strong paranoid features or short-term psychotic symptoms may not be able to understand situations accurately. In this case, their disorder may affect their cognitive ability.
For volitional ability, Dr. Abdalla-Filho compared kleptomania, a compulsion to steal, to personality disorders. People with kleptomania are aware that their behaviour is illegal but lack control over their impulse to steal. Similarly, people with a personality disorder may lack control over their impulsive or explosive behaviour, despite understanding that their behaviour is illegal or harmful.
Dr. Abdalla-Filho also said that psychopathic behaviour, which stems from disordered personalities, may sometimes not depend on the person’s will, as many mental health professionals believe. Recent research shows that psychopathic behaviour can result from changes in the normal function of the brain, affecting a person’s decisions.
One study looked at impairment of a specific part of the brain, the temporoparietal junction. When this junction is impaired, people cannot evaluate other people’s intentions in committing an act but only the results of the act.
Another study showed that people with antisocial personality disorder have about 11 per cent less grey matter in the prefrontal cortex. However, a common misconception is that psychopathy always stems from a personality disorder with antisocial characteristics, when in fact, narcissistic traits are more prone to psychopathic behaviour.
Classification Challenges
Another difficulty in assessing people with personality disorders is how to classify these disorders. The International Classification of Diseases, 10th Revision (ICD-10), has a classification system based on categories. Another type of classification, the dimensional one, grades personality disorders as mild, moderate, or severe, considering several dimensions of the disorders. There is also a classification approach, the hybrid one, that uses both categories and dimensions. An approach based on several dimensions provides a more careful assessment of the person’s criminal responsibility. But many mental health professionals still use the categories-based ICD-10, possibly because it is easier to use. (For more information, read Dr. Abdalla-Filho’s book Personality disorders in the 10th and 11th editions of the International Classification of Diseases. Cambridge Scholars Publishing, 2022.)
Because of these issues, assessing criminal responsibility in people with personality disorders should be more complex and in-depth than it has been.
All mental health professionals must have better technical and emotional preparation when assessing people with personality disorders, says Dr. Abdalla-Filho. Preparation helps professionals recognize and cope with scientific limitations and their own emotional difficulties.
For more details, watch the recording of the February 12, 2026, lecture, “Let’s Be Honest About Personality Disorders” on our website.
Written by Carolyn Brown and approved by Dr. Elias Abdalla-Filho.
