Circular No. 18/2015/TT-BYT Issuing the forensic psychiatric examination procedure and forms used in forensic psychiatric examinations

CIRCULAR

Issuing the forensic psychiatric examination procedure and forms to be used in forensic psychiatric examinations used in forensic psychiatric examinationsFor power plants invested under the Build-Operate-Transfer (BOT) model, n is determined according to the operational period of the power plant stipulated in the BOT contract.

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Pursuant to the Law on Forensic Appraisal No. 13/2012/QH13 dated June 20, 2012;

Pursuant to Decree No. 85/2013/NĐ-CP dated July 29, 2013 of the Government detailing and providing implementation measures for the Law on Forensic Appraisal;

This Circular prescribes procedures for receiving, providing health care for domestic violence victims and statistical reports on domestic violence victims at medical facilities.

At the proposal of the Director of the Department of Medical Examination and Treatment,

The Minister of Health issues this Circular on forensic psychiatric examination procedures and forms for use in forensic psychiatric examinations.

Article 1. Issuing the forensic psychiatric examination procedure

The forensic psychiatric examination procedure accompanying this Circular includes:

1. Part I. General Procedure for Forensic Psychiatric Examination;

2. Part II. Procedure for Forensic Psychiatric Examination of 21 Common Mental Disorders.

Article 2. Issuing the forms to be used in forensic psychiatric examinations

The forms to be used in forensic psychiatric examinations accompanying this Circular include 13 forms.

Article 3. Scope of Application

The forensic psychiatric examination procedure and the forms to be used in forensic psychiatric examinations accompanying this Circular shall be uniformly applied in forensic psychiatric examinations.

Article 4. Effective date

This Circular takes effect from August 15, 2015.

Article 5. Responsibilities for Implementation

1. The Department of Medical Examination and Treatment shall take the lead and coordinate with relevant agencies and units to direct, guide, and inspect the implementation of this Circular throughout the country.

2. The Central Institute of Forensic Psychiatry shall be responsible for guiding and inspecting forensic psychiatric expertise professionally and operationally for regional forensic psychiatry centers and organizations conducting forensic psychiatric examinations nationwide in accordance with the provisions of this Circular. During the implementation process, if there are difficulties or obstacles, agencies, organizations, and individuals are requested to promptly report to the Ministry of Health for consideration and resolution.

In the course of implementation, if there are difficulties or obstacles, agencies, organizations, and individuals are advised to promptly report to the Ministry of Health for consideration and resolution./.

 

PROCEDURE

FORENSIC PSYCHIATRIC APPRAISAL
(Issued together with Circular No. 18/2015/TT-BYT dated July 14, 2015 of the Minister of Health)

Part I

GENERAL PROCEDURE FOR FORENSIC PSYCHIATRIC APPRAISAL

I. Preparing Necessary Conditions for Conducting the Appraisal

1. Participants in the Appraisal

1.1. The forensic psychiatric appraiser is a psychiatrist specializing in mental health who has been appointed by the competent authority as a forensic psychiatric appraiser or a case-specific forensic psychiatric appraiser (collectively referred to as the appraiser). Typically, each forensic psychiatric appraisal involves three appraisers. In complex cases where it is difficult to determine the illness and assess capacity, five appraisers may participate. For a second re-appraisal involving multiple specialties, additional experts in forensic psychiatric appraisal may be invited, but the total number should not exceed nine people per appraisal.

1.2. Nursing staff managing, monitoring, and caring for the person being appraised. Each appraisal requires two nursing assistants.

1.3. A person sent by the requesting party to assist in managing the person being appraised (in cases where the person is under detention).

2. Equipment, Means, and Medications

2.1. Room for holding the person being appraised: Ensuring safety and ease of observation.

2.2. Surveillance camera (as necessary).

2.3. Camera, audio recorder.

2.4. Diagnostic equipment, imaging, and functional testing means.

2.5. Means and tools for psychological tests.

2.6. Medications, examination, and treatment equipment when necessary.

2.7. Means for verification, specialty examination, and emergency care for the person being appraised when necessary.

Depending on the type of appraisal, the forensic psychiatric appraisal organization must prepare appropriate equipment, means, and medications. If the forensic psychiatric appraisal organization does not have all the required means, it may contract with other agencies or organizations that have the necessary means and capabilities to perform them.

3. Request or Demand for Appraisal Files

3.1. The request or demand for appraisal file provided by the requesting or demanding party and bears responsibility for the legality of the file according to Point c Clause 2 Article 21, Point a Clause 3 Article 22 of the Law on Forensic Appraisal.

3.2. The file must be sent to the forensic psychiatric organization at least ten working days in advance for study.

3.3. The request for appraisal file includes:

a) Decision to request forensic psychiatric appraisal issued by the requesting party containing the contents stipulated in Clause 2 Article 25 of the Law on Forensic Appraisal, signed and stamped by the authorized person.

b) Relevant materials related to the forensic psychiatric appraisal including:

- The subject's personal history;

- Investigation materials collected in the case;

- Statements of the subject;

- Declarations of the subject;

- Witness statements;

- Victim declarations;

- Observations of the detention facility (if applicable) including observations of: Wardens, prison medical staff, co-inmates regarding the subject's daily activities and behavior;

- Indictment (if applicable);

- Court record (if applicable).

c) Materials related to the health of the subject (especially the subject's mental health), including:

- Observations of local authorities or government bodies about the subject;

- Local medical observations about the subject's health condition, confirmed by the head of the commune, ward, or town health station (hereinafter referred to as the commune-level health station);

- Observations of at least two neighbors (who are not relatives or close associates of the subject);

- Family reports on the characteristics, health conditions, development from childhood to the present of the subject, specifying whether the subject has used alcohol or drugs;

- Copies of medical records from healthcare facilities that have treated the subject, related examination and treatment materials of the subject (if applicable).

3.4. The demand for appraisal file includes:

a) Legal document requesting forensic appraisal containing the contents stipulated in Clause 2 Article 26 of the Law on Forensic Appraisal;

b) Copy of documents as stipulated in Clause 1 Article 26 of the Law on Forensic Appraisal;

c) Materials as stipulated in Point 3.3.c Clause 3 Section I Part I of this Procedure.

4. Subject of the Appraisal

4.1. The subject of the appraisal is a living person brought by the requesting or demanding party to the forensic psychiatric organization upon its agreement to accept the appraisal.

4.2. In cases where the subject of the request for opinion or the subject of the forensic psychiatric examination has died or gone missing and such facts have been confirmed by the competent authority, or in other cases as prescribed by relevant laws, the forensic psychiatric organization will conduct the examination based on the file provided by the requester or the person making the request.

II. Procedures for various forms of forensic psychiatric examinations

Based on actual circumstances and the nature of each case, forensic psychiatric organizations select an appropriate form of examination according to the procedures of one of the following examination forms:

1. Inpatient Examination

This is an examination conducted at a forensic psychiatric examination facility, applicable to cases where diagnosing the illness and determining the capacity of the examined subject is difficult and complex.

1.1. Receiving the Request File:

a) The request file in accordance with Point 3.3 or Point 3.4 Clause 3 Section I Part I of this Procedure. The file must be submitted to the forensic psychiatric organization at least ten working days in advance for review, consideration, and decision on accepting the request for examination, and assigning personnel to carry out the examination;

b) Accepting the request for examination and receiving the request file in accordance with Clause 1, Clause 2, and Clause 3 Article 27 of the Law on Forensic Examinations;

c) Within five working days from the date of receipt of the complete request file, the forensic psychiatric organization must provide a written response to the requester or the person requesting the examination regarding the acceptance of the examined subject. If the request is not accepted, the refusal reasons must be clearly stated in the written response.

1.2. Refusal to Conduct Examination:

The forensic psychiatric organization refuses to conduct an examination when one of the situations prescribed in Clause 2 Article 11 of the Law on Forensic Examinations occurs.

1.3. Acceptance of the Examined Subject:

After the head or authorized representative of the forensic psychiatric organization agrees in writing to accept the request, the requester or the person requesting the examination shall bring the examined subject to hand over to the forensic psychiatric organization. The handover of the examined subject is carried out in accordance with Clause 4 and Clause 5 Article 27 of the Law on Forensic Examinations and a handover record must be established according to the model issued together with this Circular, depending on the examined subject.

1.4. Assignment of Personnel for the Examination:

The head of the forensic psychiatric organization issues a decision to assign personnel for the forensic psychiatric examination. The assigned forensic psychiatric examiners (hereinafter referred to as participating examiners) operate under the collective examination mechanism stipulated in Clause 3 Article 28 of the Law on Forensic Examinations, including the assignment of a chief examiner and a secretary examiner.

1.5. Reviewing the Request File:

All participating examiners must review the file provided by the requester or the person requesting the examination. If necessary, the participating examiners may uniformly request the organization or individual requesting the examination to supplement materials or send an examiner to collect additional materials together with the person being examined. The secretary examiner compiles all relevant materials related to the examined subject.

1.6. Monitoring the Examined Subject:

a) The examined subject is placed in an observation room. If necessary, monitoring can be done through cameras.

b) Participating examiners closely observe and meticulously record every development of the examined subject in the observation medical record:

- In cases requiring treatment for the examined subject: The forensic psychiatric organization convenes a consultation in accordance with the Ministry of Health's regulations and unifies the treatment direction. Outside regular working hours, if emergency treatment is needed, the on-duty doctor treats and records the developments of the examined subject in the observation medical record.

- The maximum observation period is six weeks per examined subject.

If it is necessary to extend the observation period, the participating examiners must report to the head of the forensic psychiatric organization for consideration and decision on extending the observation period, and notify the requesting agency or individual in writing along with the reasons.

1.7. Clinical Examination of the Examined Subject:

a) Mental examination: Detailed and meticulous examination of all mental activities;

b) Internal medicine and neurology examination;

c) Other specialty examinations (if necessary).

Participating examiners must directly conduct a clinical examination of the examined subject before conducting the examination.

The secretary examiner must fully record all clinical developments in the observation medical record.

1.8. Ancillary Clinical Examination of the Examined Subject:

a) Necessary tests:

- Blood test (biochemistry, hematology);

- Urine test;

- Chest X-ray (frontal or lateral);

- Skull and brain X-ray (frontal and lateral);

- Electroencephalogram;

- Electrocardiogram;

- Psychological tests.

b) Other tests:

Depending on specific cases, the examiner may instruct the examined subject to undergo necessary tests among the following and bear responsibility for their instructions:

- Brain hemorrhage test;

- CT scan or MRI of the skull and brain;

- HIV test;

- Other necessary tests.

1.9. The secretary examiner compiles all relevant materials concerning the examined subject.

1.10. Meeting of Participating Examiners:

- The secretary examiner reports a summary of the case file and the observation process;

- Participating examiners directly examine the clinical condition of the examined subject and present their opinions;

- Discussion, conclusion of the examination and examination minutes.

1.11. Examination Conclusion and Minutes:

Based on: results of studying the examined subject's materials; clinical and ancillary clinical signs and the degree of illness/non-illness of each examined subject; specific cases related to the examined subject, participating examiners draw conclusions and compile examination minutes.

The conclusions and records of the examination must fully address the contents of the request for examination or the examination requirements and be documented in writing.

All examiners participating in the examination must sign the conclusion and record of the examination. If there is disagreement among the examiners, their opinions must be clearly stated. Examiners have the right to reserve their own conclusions and bear legal responsibility for those conclusions.

a) Medical conclusions:

- Based on the Diagnostic Criteria of the World Health Organization for Mental Disorders and Behavioral Disorders (ICD-10), and based on Circular No. 20/2014/TT-BYT dated June 12, 2014 issued by the Minister of Health regarding the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the examiners participating in the examination determine the subject of the examination:

- Identity card number or personal identification number

- Whether there is a mental illness or mental disorder? What kind of mental illness or mental disorder (record the code)? The mental state before, during, and after the incident?

b) Conclusions on the ability to understand and control behavior (at each time point, especially at the time of the incident):

- Loss of the ability to understand and/or control behavior;

- Limited ability to understand and/or control behavior;

- Sufficient ability to understand and control behavior.

1.12. Establishing and storing examination files

a) Establishing examination files:

In addition to the documents specified in Point 3.3 or Point 3.4 Clause 3 Section I Part I of this Procedure, the examination file also includes additional documents (records used during forensic psychiatric examinations):

- Records of document handover and records of handover and receipt of the examination subject;

- Documentation of the examination process, including: Follow-up examination medical records; Forensic psychiatric examination records;

- Examination conclusions;

- Photos of the examination subject;

- Other relevant documents related to the examination (if any).

b) The examination file is stored by the forensic psychiatric organization. The storage period for the examination file is in accordance with the law on archiving (permanent storage).

1.13. Completion of the examination:

a) The forensic psychiatric organization returns the examination subject to the requesting party or the party requesting the examination. Depending on the examination subject, both parties sign the record of handover of the examination subject (the examination subject has a detention order or does not have a detention order);

b) Delivering the examination conclusions and records: the forensic psychiatric organization delivers the examination conclusions and records directly to the person designated by the requesting party or the party requesting the examination (with a signature receipt) or delivers them indirectly through postal service, with a confirmation stamp from the postal service (registered mail).

2. On-site Examination at Clinic

Applied to cases that are simple and not difficult in diagnosis, determination of capacity, and liability for conduct.

2.1. Receiving Request or Examination Requirement Files:

As stipulated in Point 1.1 Clause 1 Section II Part I of this Procedure.

2.2. Assigning Participants in the Examination:

As stipulated in Point 1.4 Clause 1 Section II Part I of this Procedure.

2.3. Studying Request or Examination Requirement Files:

As stipulated in Point 1.5 Clause 1 Section II Part I of this Procedure.

2.4. Receiving and Clinically Examining the Examination Subject:

Receiving the examination subject at the clinic of the forensic psychiatric organization for the examiners to clinically examine the subject. The examination of the subject is conducted according to the provisions of Point 1.7 Clause 1 Section II Part I of this Procedure.

2.5. Conducting Adjunct Clinical Examinations of the Examination Subject:

Depending on specific circumstances, the examiners may agree to have the examination subject undergo adjunct clinical examinations (tests) as stipulated in Point 1.8 Clause 1 Section II Part I of this Procedure. The requesting party or the party requesting the examination will take the examination subject for testing.

2.6. The secretary examiner compiles all relevant documents pertaining to the examination subject.

2.7. Meeting of Participating Examiners:

Based on the study of the request or examination requirement files, the results of direct clinical examination of the subject at the clinic, and the results of adjunct clinical examinations performed, the participating examiners discuss, conclude, and prepare the examination record.

2.8. Examination Conclusions and Records:

As stipulated in Point 1.11 Clause 1 Section II Part I of this Procedure.

2.9. Establishing and Storing Examination Files:

As stipulated in Point 1.12 Clause 1 Section II Part I of this Procedure.

2.10. Completion of the Examination:

As stipulated in Point 1.13 Clause 1 Section II Part I of this Procedure.

3. On-site Examination

Applied to cases where the examination subject is detained and it would be difficult and unsafe to bring them out for examination, or in some special cases where the subject cannot be brought to the examination organization.

3.1. Receiving Request or Examination Requirement Files:

As stipulated in Point 1.1 Clause 1 Section II Part I of this Procedure.

3.2. Assigning Participants in the Examination:

As stipulated in Point 1.4 Clause 1 Section II Part I of this Procedure.

3.3. Studying Request or Examination Requirement Files:

As stipulated in Point 1.5 Clause 1 Section II Part I of this Procedure.

3.4. Contacting and Examining the Examination Subject:

Contacting the examination subject at the place where they are detained for the examiners to examine the subject. The examination of the subject is conducted according to the provisions of Point 1.7 Clause 1 Section II Part I of this Procedure.

3.5. Taking the Examination Subject for Necessary Adjunct Clinical Examinations:

Depending on specific circumstances, the examiners may agree to have the examination subject undergo necessary adjunct clinical examinations (tests) as stipulated in Point 1.8 Clause 1 Section III Part I of this Procedure. The requesting party or the party requesting the examination will take the examination subject for testing.

3.6. The secretary examiner compiles all relevant documents pertaining to the examination subject.

3.7. Meeting of Participating Examiners:

Based on the study of the request or examination requirement files, the results of direct examination of the subject, and the results of adjunct clinical examinations performed, the participating examiners discuss, conclude, and prepare the examination record.

3.8. Examination Conclusions and Records:

As stipulated in Point 1.11 Clause 1 Section II Part I of this Procedure.

3.9. Establishing and Storing Examination Files:

As stipulated in Point 1.12 Clause 1 Section II Part I of this Procedure.

3.10. Completion of the Examination:

As stipulated in Point 1.13 Clause 1 Section II Part I of this Procedure.

4. Examination based on files (absentee examination)

This form shall only be applied in cases where the subject of examination has died, gone missing, or in other cases as prescribed by relevant laws.

4.1. Receiving the examination request file or the examination requirement file:

As stipulated in Point 1.1 Clause 1 Section II Part I of this Procedure.

4.2. Assigning individuals to participate in the examination:

As stipulated in Point 1.4 Clause 1 Section II Part I of this Procedure.

4.3. Studying the examination request file or the examination requirement file:

As stipulated in Point 1.5 Clause 1 Section II Part I of this Procedure.

4.4. The examination secretary compiles all relevant documents pertaining to the subject of examination.

4.5. Holding a meeting of the examination participants:

Based on the study of the examination request file or the examination requirement file, the examination participants discuss, draft the examination conclusion, and prepare the examination record.

4.6. Examination conclusion and examination record:

As stipulated in Point 1.11 Clause 1 Section II Part I of this Procedure.

4.7. Preparing the examination file and storing the examination file:

In accordance with Point 1.12 Clause 1 Section II Part I of this procedure.

4.8. Completion of the examination:

In accordance with Point 1.13 Clause 1 Section II Part I of this procedure.

5. Supplementary examination

This form is applied in cases where the content of the examination conclusion is unclear, incomplete, or when new issues arise related to the circumstances of the case that have already been examined previously, or according to supplementary examination requests.

5.1. Receiving the supplementary examination request file or the supplementary examination requirement file:

In accordance with Point 1.1 Clause 1 Section II Part I of this procedure, along with documents related to the new circumstances of the case that have already been concluded, copies of the forensic psychiatric examination conclusions.

5.2. Assigning individuals to participate in the supplementary examination:

As stipulated in Point 1.4 Clause 1 Section II Part I of this Procedure.

The supplementary examination participants are the same examiners who participated in the initial examination.

5.3. Studying the supplementary examination request file or the supplementary examination requirement file:

As stipulated in Point 1.5 Clause 1 Section II Part I of this Procedure.

5.4. The examination secretary compiles all relevant documents pertaining to the subject of examination.

5.5. Holding a meeting of the supplementary examination participants:

Based on the study of the supplementary examination request file or the supplementary examination requirement file, the examination participants discuss, draft the examination conclusion, and prepare the supplementary examination record.

5.6. Examination conclusion and supplementary examination record:

As stipulated in Point 1.11 Clause 1 Section II Part I of this Procedure.

Fully answer the contents of the examination request decision or the supplementary examination request document.

5.7. Preparing the supplementary examination file and storing the supplementary examination file:

In accordance with Point 1.12 Clause 1 Section II Part I of this procedure, depending on the content of the examination request decision or the supplementary examination request document.

5.8. Completion of the supplementary examination:

In accordance with Point 1.13 Clause 1 Section II Part I of this procedure.

The supplementary examination conclusion must be kept in the examination file.

6. Re-examination

This form is carried out in cases where there is evidence that the initial examination conclusion is inaccurate or as provided for in Clause 2 Article 30 of the Law on Forensic Examination. Examiners who participated in the initial examination may not participate in the re-examination.

The steps in the re-examination process follow the initial examination process.

7. Second re-examination

This form is carried out in cases where there is a difference between the initial examination conclusion and the re-examination conclusion regarding the same examination content, and is decided by the party requesting the examination. The second re-examination must be conducted by the Re-examination Board.

The Re-examination Board for the second re-examination is established by the Minister of Health's decision. The second re-examination board consists of at least three members and a maximum of nine members.

The steps in the second re-examination process follow the initial examination process.

Part II

FORENSIC PSYCHIATRIC EXAMINATION PROCEDURE

OF 21 COMMON MENTAL DISORDERS AND PSYCHOTIC DISORDERS

I. Examination Procedure

1. Necessary conditions and steps for conducting forensic psychiatric examinations are implemented according to the general procedure stipulated in Part I of this procedure.

2. Examination Conclusion and Record:

a) Implemented according to the provisions of Section II of this part.

b) The examination conclusion and record must fully answer the contents of the examination request decision or the examination requirement and be prepared in writing.

c) All participating examiners must sign the examination conclusion and record. If there is disagreement among examiners, their opinions must be clearly recorded. Examiners have the right to reserve their conclusions and bear legal responsibility for them.

II. Examination Conclusion and Record of Forensic Psychiatry of 21 Common Mental Disorders and Psychotic Disorders

During the examination, participating examiners base their conclusions and records on: results of studying the subject's documents; clinical and paraclinical signs and the degree of illness/non-illness of each specific subject; specific cases related to the subject, and they are responsible for their conclusions.

1. Examination Conclusion and Record of Forensic Psychiatry of Actual Organic Hallucinations (F06.0)

1.1. Medical Conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Evidence of brain injury, neurological disease, or systemic body disease leading to brain dysfunction;

- Finding a temporal relationship (several weeks or months) between the underlying organic condition and the onset of the mental syndrome;

- Recovery of the mental disorder closely related to the loss or reduction of the organic cause;

- No evidence suggesting an "endogenous" cause (such as a severe family history of schizophrenia or mood disorder... ) or a stress-induced illness;

- Persistent or recurring hallucinations in any form (usually auditory or visual);

- Possible formation of delusions based on hallucinations;

- No impairment of consciousness;

- No significant intellectual decline;

- No dominant mood disorder;

- No dominant delusion.

1.2. Conclusion on the ability to perceive and control behavior (at each point in time, especially at the time of the incident):

a) Loss of the ability to perceive and/or control behavior:

- Progression stage;

- Content of hallucinations directly influencing behavior.

b) Limited ability to perceive and/or control behavior:

- Remission stage;

- Content of hallucinations not directly influencing behavior.

c) Full ability to perceive and control behavior: stable phase, no more hallucinations.

2. Conclusion of the forensic psychiatric examination and record for delusional disorder with organic brain damage (F06.2)

2.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Evidence of brain injury, neurological disease, or systemic bodily disease leading to brain dysfunction;

- Temporal relationship (several weeks or a few months) between the underlying organic condition and the onset of the mental syndrome;

- Recovery of the mental disorder closely related to the loss or reduction of the organic cause;

- Various types of delusions (persecution, transformation of self, jealousy, illness, guilt, bizarre delusions...);

- Occasional hallucinations, thought disorders, or muscle tension phenomena may appear.

2.2. Conclusion on the ability to perceive and control behavior (at each point in time, especially at the time of the incident).

a) Loss of the ability to perceive and/or control behavior:

- Progression stage;

- Content of delusions directly influencing behavior.

b) Limited ability to perceive and/or control behavior:

- Remission stage;

- Content of delusions not directly influencing behavior.

c) Full ability to perceive and control behavior: stable phase, no more delusions.

3. Conclusion of the forensic psychiatric examination and record for personality disorder with organic brain damage (F07.0)

3.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Evidence of brain injury, neurological disease, or brain dysfunction;

- Significant changes in behavioral patterns familiar to the patient before the onset of the disease.

- Must include at least three of the following manifestations:

+ Reduced capacity to maintain purposeful activities;

+ Emotional response disorder;

+ Expressing needs and impulses without regard for consequences or social conventions;

+ Cognitive disturbances in the form of paranoia or paranoid ideas;

+ Marked reduction in speech rate and flow;

+ Behavioral sexual disorders.

3.2. Conclusion on the ability to perceive and control behavior (at each point in time, especially at the time of the incident).

a) Loss of the ability to perceive and/or control behavior:

- During an impulse;

- Severe personality change.

b) Limited ability to perceive and/or control behavior:

- Moderate personality change;

- Mild personality change but influenced by stimulating factors (provoked, incited, etc.).

c) Full ability to perceive and control behavior: when mild personality change does not directly affect behavior.

4. Conclusion of the forensic psychiatric examination and record for post-concussion syndrome (F07.2)

4.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

4.1.1. Name and surname;

4.1.2. Presence of mental illness or mental disorder? What mental illness or mental disorder (disease code)? Mental state before, during, and after the incident? Specifically:

a) Definitive diagnosis:

- Must have evidence of sufficient head trauma causing loss of consciousness;

- At least three of the following descriptions must be present:

+ Headache, dizziness;

+ Fatigue;

+ Insomnia;

+ Irritability;

+ Difficulty concentrating, performing intellectual tasks.

+ Memory impairment;

+ Reduced tolerance to stress, emotional stimuli, or alcohol.

- May be accompanied by anxiety, depression, hypochondria;

- If the electroencephalogram is in a stimulated state, it further increases the diagnostic value.

b) Determination of severity:

- Traumatic debility: alert consciousness, headache, insomnia, persistent fatigue, unstable emotions easily triggered.

- Traumatic brain injury: difficulty in perception; poor flexible thinking, impoverished; emotions often change, easily explosive, may experience apathetic states; memory impairment; may be accompanied by localized neurological injuries.

- Note: Traumatic epilepsy is listed under G40, Traumatic dementia is listed under F02.8.

4.2. Conclusion on the ability to perceive and control behavior (at each point in time, especially at the time of the incident):

a) Limited ability to perceive and control behavior: when the disease is at the traumatic brain injury level.

b) Full ability to perceive, limited ability to control behavior: when the disease is at the traumatic debility level.

c) Full ability to perceive and control behavior: when the disease is in a stable phase.

5. Conclusion of the forensic psychiatric examination and record for mental disorders and behaviors due to alcohol and opiate use (F10, F11)

5.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

5.1.1. Name and surname;

5.1.2. Presence of mental illness or mental disorder? What mental illness or mental disorder (disease code)? Mental state before, during, and after the incident? Specifically:

a) There is sufficient evidence of substance use affecting the mind.

b) Diagnostic criteria for each clinical state:

- Acute intoxication (F1x.0): A transient pathological state following the use of substances affecting the mind, with symptoms including: altered consciousness, perception, sensory disturbances, emotional and behavioral disorders. Directly related to the dosage of the substance but not related to prolonged use.

- Addiction syndrome (F1x.2): At least three of the following manifestations:

+ Intense desire or feeling compelled to use substances affecting the mind;

+ Difficulty controlling the habit of using substances affecting the mind regarding timing, duration, or quantity;

+ A physical withdrawal state when substance use is stopped or reduced;

+ Tolerance to the substance;

+ Neglecting previous interests or pleasures;

+ Continuing to use substances despite knowing their harmful effects.

- Withdrawal state (F1x.3):

+ Evidence of addiction to substances affecting the mind;

+ During the period of cessation of substance use;

+ Intense craving for substances affecting the mind;

+ Autonomic nervous system disorders;

+ Anxiety, depression, sleep disorders;

+ Sensory disturbances;

+ Physical symptoms vary depending on the substance previously used;

+ Withdrawal symptoms decrease when the substance is used again.

- Withdrawal with delirium (F1x.4):

+ Withdrawal state;

+ Confused and disoriented consciousness;

+ Vivid hallucinations and illusions;

+ Severe tremor symptoms;

+ Often accompanied by delusions, agitation, sleep disorders;

+ Severe autonomic nervous system disorder.

- Psychotic disorder (F1x.5):

+ Psychotic symptoms appear during or immediately after the use of psychoactive substances;

+ Vivid hallucinations (typically auditory hallucinations);

+ Misidentification phenomena;

+ Delusions and/or delusional ideas;

+ Psychomotor disturbances (agitation or stupor);

+ Emotional disturbances;

+ May have a vague awareness but not leading to severe confusion.

- Residual psychotic state and late onset (F1x.7):

+ In history, there was a prolonged period of using psychoactive substances;

+ Psychotic symptoms directly caused by the use of psychoactive substances persist even after the symptoms subside;

+ Cognitive changes;

+ Emotional disturbances;

+ Personality and behavioral changes.

5.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident).

a) Loss of cognitive ability and/or control of behavior:

- Withdrawal state with delirium;

- Psychotic disorder: influenced by delusions and/or hallucinations.

b) Limited cognitive ability and/or control of behavior: personality and behavioral changes, and/or some mental disorders.

c) Sufficient cognitive ability and control of behavior: no personality changes and no mental disorders.

6. Conclusion of forensic psychiatric examination and report for Schizophrenia (F20)

6.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

c) Groups of symptoms for diagnosis:

- Audible thinking, imposed or stolen thoughts, and broadcasting thoughts;

- Delusions that are tested, controlled, or passive, clearly related to bodily movements or limbs, or related to specific thoughts, behaviors, or sensations; Delusional perception;

- Persistent comment hallucinations about the patient's behavior or discussions among themselves about the patient, or other types of hallucinations originating from a part of the body;

- Persistent delusions that are culturally inappropriate and completely impossible, such as religious or political uniformity or superhuman abilities (for example, controlling weather or contacting beings from another world);

- Persistent hallucinations of any type, sometimes accompanied by transient or incomplete delusions without clear emotional content or accompanied by overly persistent or daily recurring thoughts over weeks or months;

- Disorganized thinking or inserting words while speaking, leading to unrelated or inappropriate speech or fabricated language;

- Catatonic mannerisms such as agitation, rigid posture, waxy flexibility, negativism, mutism, or stupor;

- Negative symptoms such as marked apathy, impoverished speech, blunted or inappropriate emotional responses often leading to social isolation or reduced social functioning; it must be clear that these symptoms are not caused by depression or neuroleptic drugs;

- Frequent and significant qualitative changes in character traits manifested as loss of interest, lack of purpose, laziness, obsessive thinking about oneself, and social isolation.

d) Diagnostic criteria based on ICD-10:

- At least one group of clear symptoms from groups (1) to (4), or at least two out of five groups from (5) to (9);

- Symptoms lasting at least one month;

- Exclusion: Brain disease, major depression, bipolar disorder, drug intoxication.

6.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident).

a) Loss of the ability to perceive and/or control behavior:

- Schizophrenic episode;

- Acute phase of illness;

- Influenced by delusions and/or hallucinations;

- Dementia phase.

b) Limited cognitive ability and/or control of behavior: remission phase.

c) Sufficient cognitive ability and control of behavior: stable phase.

7. Conclusion of forensic psychiatric examination and report for Schizoaffective Disorder (F21)

7.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Three or four of the following manifestations:

+ Inappropriate emotions, indifference;

+ Strange or bizarre behavior or appearance;

+ Little contact with others;

+ Odd beliefs or mystical thinking;

+ Suspiciousness or paranoid ideas;

+ Rumination, obsessions, often with content of fear, sexuality, or intrusion;

+ Occasionally, somatic-sensory or other hallucinations, depersonalization, or misperception of reality;

+ Vague, metaphorical, excessively elaborate, or stereotyped thinking and speech;

+ Occasionally, psychotic episodes.

- These manifestations exist for at least two years.

- Never met full diagnostic criteria for schizophrenia.

7.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident):

- Loss of cognitive ability and/or control of behavior:

+ Acute phase of illness;

+ Psychotic symptoms influencing behavior.

- Limited cognitive ability and/or control of behavior: remission phase.

- Sufficient cognitive ability and control of behavior: stable phase.

8. Conclusion of forensic psychiatric examination and report for Delusional Disorder (F22.0)

8.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Delusions must be the sole clinical feature and persist for at least three months, delusions may be single or a group of related delusions;

- There may be periods of mood disturbance or isolated hallucinations, but outside those periods, delusions persist;

- No schizophrenic symptoms in history such as tested delusions, broadcasting thoughts, blunted affect;

- No brain disease.

8.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident):

- Loss of cognitive ability and/or control of behavior: when delusions directly influence behavior.

- Limited cognitive ability and/or control of behavior: when delusions do not directly influence behavior.

- Sufficient cognitive ability and control of behavior: stable phase without delusions.

9. Conclusion of forensic psychiatric examination and report on acute psychotic disorder (F23)

9.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Acute onset within about two weeks;

- Duration from several weeks to several months (depending on clinical forms);

- Clinical symptoms are diverse and change rapidly, depending on clinical forms, some of the following symptoms may appear:

+ Consciousness: some have mild impairment in time and space orientation;

+ Thought: various delusions, most commonly delusion of being followed and persecuted, other bizarre delusions, delusion of control and intrusion may also occur;

+ Perception: mostly hallucinations, with auditory hallucinations being the most common, followed by visual hallucinations, other types of hallucinations are less frequent. Auditory hallucinations can have different contents such as threats, commands, conversations, comments, etc.;

+ Emotion: unstable;

+ Behavioral style: agitated, aggressive, some patients show signs of muscle tension.

c) Stress may be combined.

d) In the medical history, there is no organic cause such as brain trauma, delirium, alcohol or drug intoxication, etc.

9.2. Conclusion regarding cognitive ability and behavioral control (at each point in time, especially at the time of the incident):

a) Loss of cognitive ability and behavioral control:

- Acute phase;

- Influenced by delusions and/or hallucinations;

- Emotional and behavioral agitation.

b) Limited cognitive ability and/or behavioral control: during the remission phase of the illness.

c) Sufficient cognitive ability and control of behavior: stable phase.

10. Conclusion of forensic psychiatric examination and report on emotional dysregulation schizophrenia (F25)

10.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Meets diagnostic criteria for schizophrenia;

- Meets diagnostic criteria for mood disorder;

- Both emotional and schizophrenic symptoms are prominent in the same phase of the disease, usually occurring simultaneously but at least separated by a few days.

10.2. Conclusion regarding cognitive ability and behavioral control (at each point in time, especially at the time of the incident):

a) Loss of the ability to perceive and/or control behavior:

- Schizophrenic agitation;

- Mood agitation;

- Acute phase of illness;

- Influenced by delusions and/or hallucinations.

b) Limited cognitive ability and/or behavioral control: during the remission phase of the illness.

c) Sufficient cognitive ability and control of behavior: stable phase.

11. Conclusion of forensic psychiatric examination and report on manic phase (F30)

11.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Mood: varying degrees of euphoria;

- Thought: disorganized thinking; excessively grandiose ideas that may develop into delusions, other types of delusions not consistent with mood may appear;

- Activity: increased energy leading to excessive activity, may have a state of agitation;

- Reduced attention and insomnia;

- Some severe cases may experience hallucinations.

11.2. Conclusion regarding cognitive ability and behavioral control (at each point in time, especially at the time of the incident):

a) Loss of the ability to perceive and/or control behavior:

- Acute phase of illness;

- Influenced by delusions and/or hallucinations.

b) Limited ability to perceive and/or control behavior:

- Remission phase;

- Mild manic phase.

c) Sufficient cognitive ability and control of behavior: stable phase.

12. Conclusion of forensic psychiatric examination and report on bipolar disorder (F31)

12.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Alternating manic and depressive phases;

- Recurrent manic episodes at least twice;

- May have psychological trauma.

12.2. Conclusion regarding cognitive ability and behavioral control (at each point in time, especially at the time of the incident):

a) Loss of the ability to perceive and/or control behavior:

- Acute phase of illness;

- Manic phase (with or without psychotic symptoms);

- Severe depressive phase (with or without psychotic symptoms);

- Influenced by delusions and/or hallucinations;

b) Limited ability to perceive and/or control behavior:

- Remission phase;

- Mild manic phase;

- Mild to moderate depressive phase.

c) Sufficient cognitive ability and control of behavior: stable phase.

13. Conclusion of forensic psychiatric examination and report on depressive phase (F32)

13.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Three main symptoms:

+ Depressed mood;

+ Loss of interest and pleasure;

+ Fatigue and reduced activity.

- Seven additional symptoms:

+ Decreased concentration and attention;

+ Decreased self-esteem and confidence;

+ Guilt and unworthiness. In severe cases, delusions of guilt or self-accusation or critical auditory hallucinations may appear;

+ Pessimistic view of the future;

+ Thoughts and behaviors of self-harm or suicide;

+ Sleep disturbance;

+ Poor appetite.

The above symptoms last at least two weeks.

- Mild depressive phase (F32.0): at least two main symptoms and two additional symptoms.

- Moderate depressive phase (F32.1): at least two main symptoms and three additional symptoms.

- Severe depressive phase without psychotic symptoms (F32.2): all three main symptoms and four additional symptoms.

- Severe depressive phase with psychotic symptoms (F32.3): meets the diagnostic criteria for F32.2, accompanied by delusions, hallucinations, or stupor, depression.

13.2. Conclusion regarding cognitive ability and behavioral control (at each point in time, especially at the time of the incident):

a) Loss of cognitive ability and/or control of behavior:

- Severe depressive phase with or without psychotic symptoms;

- Delusions and/or hallucinations influencing;

- Depressive agitation.

b) Limited cognitive ability and/or behavioral control:

- Moderate depressive phase;

- Mild depressive phase.

c) Adequate cognitive ability and behavioral control: stable phase of the illness.

14. Conclusion of forensic psychiatric examination and report on acute stress reaction (F42.0)

14.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- The disease often occurs immediately or within a few minutes after a severe trauma. Additionally, the following symptoms appear:

+ Stupor state with narrowed consciousness and attention, inability to understand stimuli and disorientation;

+ Autonomic nervous system disorder syndrome.

- Symptoms usually appear for several minutes when stimulated or stressed and disappear within 2-3 days.

14.2. Conclusion regarding cognitive ability and behavioral control (at each point in time, especially at the time of the incident):

a) Loss of cognitive ability and behavioral control:

- Stupor state;

- Narrowed consciousness;

- Disorientation.

b) Limited cognitive ability and/or behavioral control: when symptoms have subsided.

c) Adequate cognitive ability and behavioral control: phase without acute stress symptoms.

15. Conclusion of forensic psychiatric examination and report on adjustment disorders (F43.2)

15.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Evidence of stressful event or life crisis situation.

- Depressed mood, anxiety, worry, tension, and anger;

- May be accompanied by behavioral disorders: aggression or social opposition;

- Difficulty in adapting to the current living environment;

- Decrease in work performance and daily routines;

- Typically, the disease begins within one month after a stressful event or life change and symptoms usually do not last more than six months.

15.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident).

a) Adjustment disorder does not cause loss of cognitive ability and control of behavior.

b) Limitation of cognitive ability and/or control of behavior: during the progression phase of the illness.

c) Adequate cognitive ability and behavioral control: stable phase of the illness.

16. Conclusion of the forensic psychiatric examination and record of Paranoid Personality Disorder (F60.0)

16.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Diagnostic criteria for specific personality disorders:

+ Personality disorder tends to appear in late childhood or adolescence and continues to manifest in adulthood;

+ Symptoms of personality disorder are persistent and lifelong;

+ No evidence of organic brain diseases or other mental disorders;

+ The patient is aware of and distressed by their abnormal traits but cannot adjust them.

- At least three of the following characteristics:

+ Excessive sensitivity to failure or rejection;

+ Persistent tendency towards hostility, for example, unwilling to forgive insults, injuries, contempt;

+ Suspiciousness and a tendency to distort events by interpreting innocent and friendly actions of others as hostile or contemptuous;

+ Persistent struggle for personal rights that are disproportionate to the actual situation;

+ Persistent unfounded suspicion about the sexual fidelity of a spouse or partner;

+ Excessive sensitivity to one's importance, manifested in a persistent self-centered attitude;

+ Preoccupation with baseless "conspiracy" explanations of events directly affecting the patient and the outside world generally.

16.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident):

a) Paranoid personality disorder does not cause loss of cognitive ability and control of behavior.

b) Limitation of cognitive ability and/or control of behavior: when personality disorder directly affects behavior.

c) Adequate cognitive ability and control of behavior: when personality disorder does not directly affect behavior.

17. Conclusion of the forensic psychiatric examination and record of Schizotypal Personality Disorder (F60.1)

17.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Diagnostic criteria for specific personality disorders:

+ Personality disorder tends to appear in late childhood or adolescence and continues to manifest in adulthood;

+ Symptoms of personality disorder are persistent and lifelong;

+ No evidence of organic brain diseases or other mental disorders;

+ The patient is aware of and distressed by their abnormal traits but cannot adjust them.

- At least three of the following characteristics:

+ Little or no activity that brings pleasure.

+ Indifferent, detached, or blunted emotions;

+ Limited ability to express warmth, affection, or anger towards others;

+ Indifference to both praise and criticism;

+ Little interest in sexual experiences with others (considering age);

+ Almost always interested in solitary activities;

+ Excessive preoccupation with fantasy and inner observation;

+ Lack of close friends or reliable relationships (or only one) and lack of desire for such relationships;

+ Lack of clear sensitivity to current social norms and rules.

17.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident):

a) Schizotypal personality disorder does not cause loss of cognitive ability and control of behavior.

b) Limitation of cognitive ability and/or control of behavior: when personality disorder directly affects behavior.

c) Adequate cognitive ability and control of behavior: when personality disorder does not directly affect behavior.

18. Conclusion of the forensic psychiatric examination and record of Antisocial Personality Disorder (F60.2)

18.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Diagnostic criteria for specific personality disorders:

+ Personality disorder tends to appear in late childhood or adolescence and continues to manifest in adulthood.

+ Symptoms of personality disorder are persistent and lifelong.

+ No evidence of organic brain diseases or other mental disorders.

+ The patient is aware of and distressed by their abnormal traits but cannot adjust them.

- At least three of the following characteristics:

+ Indifference and cruelty towards the emotions of others;

+ Irresponsible, aggressive, and persistent attitude, disregarding social norms, rules, and obligations;

+ Inability to maintain stable relationships despite having no difficulty in establishing them;

+ Very low tolerance for failure and very quick to explode into aggressive outbursts including violence;

+ Loss of ability to feel guilt or learn from punishment, particularly for retribution;

+ A clear tendency to blame others or provide seemingly acceptable reasons for behaviors that lead to conflict with society.

18.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident):

a) Antisocial personality disorder does not cause loss of cognitive ability and control of behavior.

b) Limitation of cognitive ability and/or control of behavior: when personality disorder directly affects behavior.

c) Adequate cognitive ability and control of behavior: when personality disorder does not directly affect behavior.

19. Conclusion of the forensic psychiatric examination and record of Borderline Personality Disorder (F60.3)

19.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Diagnostic criteria for specific personality disorders:

+ Personality disorder tends to appear in late childhood or adolescence and continues to manifest in adulthood;

+ Symptoms of personality disorder are persistent and lifelong;

+ No evidence of organic brain diseases or other mental disorders;

+ The patient is aware of and distressed by their abnormal traits but cannot adjust them.

- At least three of the following characteristics:

+ Pronounced tendency to act impulsively without considering consequences;

+ Mood swings that are unpredictable;

+ Possible emotional outbursts and inability to control behavioral outbursts;

+ The patient has a tendency to argue or conflict with others, especially when their actions are criticized or prevented.

19.2. Conclusion on cognitive ability and control of behavior (at each point in time, especially at the time of the incident).

a) Borderline personality disorder does not cause loss of cognitive ability and control of behavior.

b) Limitation of cognitive ability and/or control of behavior: when personality disorder directly affects behavior.

c) Adequate cognitive ability and control of behavior: when personality disorder does not directly affect behavior.

20. Conclusion of the forensic psychiatric examination and record of Mental Retardation (F70 - F79)

20.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Mild Mental Retardation (F70):

+ The patient may develop social relationship abilities before school age;

+ Most can take care of themselves and perform simple tasks at home;

+ Usually have significant difficulties with theoretical learning.

+ At maturity, has occupational skills and social relationships sufficient for independence, but encounters difficulties in handling situations;

+ IQ score within the range of 50 - 69.

- Moderate mental retardation (F71):

+ Before school age, the patient can speak or learn basic social interactions, but often lacks understanding of social rules;

+ They can be guided to take care of themselves but require supervision;

+ Some individuals can acquire basic skills necessary for reading and writing;

+ In adulthood, they may perform simple tasks if closely supervised. Rarely, they can live completely independently, but can move around easily and have good physical activity;

+ IQ score within the range of 35 - 49.

- Severe mental retardation (F72):

+ Prior to school age, the patient shows poor development in motor skills and language, with very little or no ability to communicate;

+ During schooling, they may learn to speak and understand basic issues, but usually cannot learn a trade;

+ In adulthood, they can only perform simple tasks under close supervision;

+ Most patients exhibit clear signs of motor disorders or other deficiencies;

+ IQ score within the range of 20 - 34.

- Profound mental retardation (F73):

+ Very poor development in motor functions;

+ Mostly able to communicate only through rudimentary non-verbal means;

+ Severely limited in understanding and following instructions and in self-care abilities;

+ Requires constant monitoring and care in specialized medical facilities;

+ Often has severe neurological and bodily deficiencies;

+ IQ score < 20.

Note: The IQ score serves as supportive diagnostic criteria.

20.2. Conclusion on cognitive capacity and control of behavior (at each point in time, especially at the time of the incident):

a) Loss of cognitive capacity and control of behavior: severe and very severe levels of illness.

b) Restricted cognitive capacity and control of behavior: mild and moderate levels of illness.

21. Conclusion of forensic psychiatric examination and record for epilepsy (G40)

21.1. Medical conclusion:

Based on the Diagnostic Criteria of the World Health Organization for Mental and Behavioral Disorders (ICD-10), and Circular No. 20/2014/TT-BYT dated June 12, 2014 of the Minister of Health on the percentage of bodily injury used in forensic medical and forensic psychiatric examinations, the participating examiners determine the subject of examination:

a) Full name;

b) Whether the subject suffers from mental illness or psychotic disorder? What kind of mental illness or psychotic disorder (disease code)? Mental state before, during, and after the incident? Specifically:

- Clinically: has epileptic seizures;

- Electroencephalogram (EEG): shows pathological waves consistent with clinical epileptic seizures;

Note: EEG plays a crucial role in diagnosing epilepsy but is not a decisive standard because only about 80% of epilepsy patients show pathological waves on EEG. A definitive clinical diagnosis of epilepsy is decisive.

- Determine the degree of personality change and accompanying intellectual decline.

21.2. Conclusion on cognitive capacity and control of behavior (at each point in time, especially at the time of the incident).

a) Loss of the ability to perceive and/or control behavior:

- During epileptic seizure;

- Epileptic excitation phase;

- Postictal twilight state (usually occurs after a major generalized seizure);

- Intellectual decline;

- Severe personality change.

b) Restricted cognitive capacity and/or control of behavior: outside the epileptic seizure phase, the patient exhibits moderate to mild personality changes, and/or some symptoms of mental disorder.

c) Adequate cognitive capacity and control of behavior: outside the epileptic seizure phase, the patient does not exhibit personality changes, does not have intellectual decline, and does not have mental disorder.