Avoidant personality disorder US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Avoidant personality disorder. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Avoidant personality disorder US Medical PG Question 1: A 26-year-old woman thinks poorly of herself and is extremely sensitive to criticism. She is socially inhibited and has never had a romantic relationship, although she desires one. Which of the following is the most likely diagnosis?
- A. Schizoid personality disorder
- B. Paranoid personality disorder
- C. Depression
- D. Dysthymia
- E. Avoidant personality disorder (Correct Answer)
Avoidant personality disorder Explanation: ***Avoidant personality disorder***
- Characterized by **social inhibition**, feelings of **inadequacy**, and **hypersensitivity to negative evaluation**, leading to avoidance of social interactions despite a desire for connection.
- The patient's self-perception, sensitivity to criticism, and absence of romantic relationships are classic signs.
*Schizoid personality disorder*
- Individuals with schizoid personality disorder exhibit a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- Unlike avoidant personality disorder, they typically **do not desire social connection** and are indifferent to criticism or praise.
*Paranoid personality disorder*
- Marked by pervasive **distrust and suspiciousness of others**, interpreting their motives as malevolent.
- This patient's symptoms are more focused on self-perception and social anxiety rather than paranoid ideation.
*Depression*
- Depression involves a sustained period of **low mood**, loss of interest or pleasure, and other vegetative symptoms, which are not explicitly described as the primary, long-standing issue here.
- While feelings of worthlessness can occur in depression, the chronic, pervasive social inhibition and desire for relationships point away from a primary depressive episode as the sole diagnosis.
*Dysthymia*
- Dysthymia, or persistent depressive disorder, is characterized by a chronically depressed mood for at least two years, but it usually includes more pervasive depressive symptoms like low energy and anhedonia.
- While it can involve poor self-esteem, it doesn't fully explain the specific pattern of social avoidance and hypersensitivity to criticism, especially the patient's desire for social connection, which is often dampened in dysthymia.
Avoidant personality disorder US Medical PG Question 2: A 27-year-old man is brought to a psychiatrist by his mother who is concerned that he has become increasingly distant. When asked, he says that he is no longer going out because he is afraid of going outside by himself. He says that ever since he was a teenager, he was uncomfortable in large crowds and on public transportation. He now works from home and rarely leaves his house except on mandatory business. Which of the following personality disorders is most likely genetically associated with this patient's disorder?
- A. Dependent
- B. Schizotypal
- C. Histrionic
- D. Antisocial
- E. Paranoid
- F. Avoidant (Correct Answer)
Avoidant personality disorder Explanation: ***Avoidant***
- This patient exhibits symptoms consistent with **agoraphobia**, which is an **anxiety disorder** characterized by fear of situations where escape might be difficult or help unavailable, often leading to social isolation.
- **Avoidant Personality Disorder** has the strongest genetic association with anxiety disorders, particularly **social anxiety disorder and agoraphobia**, sharing common genetic vulnerability factors related to fear of negative evaluation and social avoidance.
- Studies demonstrate significant genetic overlap between avoidant personality disorder and anxiety spectrum disorders, making this the most likely genetically associated personality disorder.
*Schizotypal*
- **Schizotypal Personality Disorder** is genetically linked to the **schizophrenia spectrum** (not anxiety disorders), characterized by cognitive-perceptual distortions, eccentric behavior, and social deficits.
- While schizotypal patients may avoid social situations, this is due to odd thinking and discomfort with close relationships, not anxiety about specific situations like crowds or public transportation.
*Dependent*
- **Dependent Personality Disorder** is characterized by an excessive need to be taken care of, leading to **submissive and clinging behavior**, and fears of separation.
- This patient's withdrawal is due to fear of public places, not a reliance on others or fear of abandonment.
*Antisocial*
- **Antisocial Personality Disorder** involves a pervasive pattern of **disregard for and violation of the rights of others**, often presenting as deceitful and impulsive behavior.
- The patient's symptoms are rooted in anxiety and social avoidance rather than a lack of empathy or antisocial behavior.
*Paranoid*
- **Paranoid Personality Disorder** is characterized by a pervasive **distrust and suspiciousness of others**, interpreting their motives as malevolent.
- The patient's withdrawal stems from fear of specific situations (crowds, public transport) rather than paranoid ideation or general suspicion of people's intentions.
*Histrionic*
- **Histrionic Personality Disorder** is marked by **excessive emotionality and attention-seeking behavior**, often displaying dramatic and superficial interactions.
- The patient's isolation and fear of public spaces are directly opposite to the attention-seeking nature of histrionic traits.
Avoidant personality disorder US Medical PG Question 3: A 20-year-old man comes to the physician because of decreasing academic performance at his college for the past 6 months. He reports a persistent fear of “catching germs” from his fellow students and of contracting a deadly disease. He finds it increasingly difficult to attend classes. He avoids handshakes and close contact with other people. He states that when he tries to think of something else, the fears “keep returning” and that he has to wash himself for at least an hour when he returns home after going outside. Afterwards he cleans the shower and has to apply disinfectant to his body and to the bathroom. He does not drink alcohol. He used to smoke cannabis but stopped one year ago. His vital signs are within normal limits. He appears anxious. On mental status examination, he is oriented to person, place, and time. In addition to starting an SSRI, which of the following is the most appropriate next step in management?
- A. Cognitive-behavioral therapy (Correct Answer)
- B. Psychodynamic psychotherapy
- C. Motivational interviewing
- D. Interpersonal therapy
- E. Group therapy
Avoidant personality disorder Explanation: **Cognitive-behavioral therapy**
- **Cognitive-behavioral therapy (CBT)**, specifically **Exposure and Response Prevention (ERP)**, is the most effective psychotherapy for **obsessive-compulsive disorder (OCD)**, which this patient's symptoms strongly suggest.
- CBT helps patients challenge distorted thoughts and gradually expose themselves to feared situations while preventing compulsive rituals, thus breaking the cycle of obsessions and compulsions.
*Psychodynamic psychotherapy*
- This therapy focuses on **unconscious conflicts** and **past experiences** to understand current symptoms.
- While it can be helpful for some mental health conditions, it is generally **less effective** than CBT for the specific, highly ritualized symptoms of OCD.
*Motivational interviewing*
- **Motivational interviewing** is a patient-centered counseling style designed to address **ambivalence about change** and enhance intrinsic motivation.
- It is often used in substance abuse or lifestyle changes, but it does not directly teach coping skills for OCD symptoms or address the underlying thought patterns.
*Interpersonal therapy*
- **Interpersonal therapy (IPT)** focuses on the patient's **current interpersonal relationships** and social functioning.
- While social difficulties can arise from OCD, IPT does not directly target the obsessions and compulsions that are central to the disorder.
*Group therapy*
- **Group therapy** can provide support and a sense of community, but for a severe condition like OCD, **individual therapy** (especially CBT/ERP) is typically recommended first due to the highly individualized nature of obsessions and compulsions.
- It may be a complementary approach, but usually not the most appropriate initial next step given the intensity of the patient's symptoms.
Avoidant personality disorder US Medical PG Question 4: A 23-year-old female college senior comes to the physician with a 1-year history of recurrent palpitations accompanied by sweating, facial blushing, and sometimes nausea. The symptoms are worse during class when she is occasionally called out to speak, which causes her to feel embarrassed. She has been skipping class on discussion days because she is concerned that her classmates may notice her symptoms. The patient does not enjoy jogging in the park anymore and has gained 2 kg (4 lbs 7 oz) over the past 2 months. Her appetite is unchanged. She has no history of serious illness. She does not smoke or drink alcohol. She has experimented with marijuana but does not use it currently. She appears nervous and does not make eye contact with the physician. Her vitals show a pulse of 85/min, her blood pressure is 125/70 mmHg, and her temperature is 36.8°C. Mental status examination reveals full range of affect. Neurological exam shows no abnormalities. Which of the following is the most likely diagnosis for this patient's symptoms?
- A. Schizotypal personality disorder
- B. Social anxiety disorder (Correct Answer)
- C. Generalized anxiety disorder
- D. Normal shyness
- E. Avoidant personality disorder
Avoidant personality disorder Explanation: ***Social anxiety disorder***
- This patient exhibits characteristic symptoms of **social anxiety disorder**, including significant anxiety in social situations (e.g., public speaking in class), fear of being judged negatively, and resulting avoidance behaviors (skipping class).
- The physical symptoms (palpitations, sweating, blushing, nausea) are typical physiological responses to social performance anxiety, and the 1-year history indicates a chronic pattern.
*Schizotypal personality disorder*
- Characterized by pervasive patterns of social and interpersonal deficits marked by **acute discomfort with, and reduced capacity for, close relationships**, as well as cognitive or perceptual distortions and eccentric behavior.
- The patient's symptoms are primarily anxiety-driven in social contexts, not due to thought disorders, magical thinking, or eccentric behaviors common in schizotypal personality disorder.
*Generalized anxiety disorder*
- Involves **excessive, uncontrollable worry** about a variety of events or activities, often not specific to social situations.
- While the patient has anxiety, it is specifically triggered by social performance and evaluation, distinguishing it from the pervasive, non-specific worry of generalized anxiety disorder.
*Normal shyness*
- While the patient is shy, her symptoms are severe enough to cause **significant distress and functional impairment**, such as skipping classes and avoiding activities she once enjoyed (jogging).
- Normal shyness typically does not lead to this level of avoidance or functional compromise, nor does it typically present with such intense physiological symptoms.
*Avoidant personality disorder*
- While both social anxiety disorder and avoidant personality disorder involve social avoidance, the latter is a more pervasive pattern involving a **deep-seated sense of inadequacy, hypersensitivity to negative evaluation**, and a fear of intimacy across many social contexts.
- The symptoms described are more acutely tied to **performance and scrutiny** in social situations rather than a global pattern of avoidant behaviors stemming from a core sense of inadequacy.
Avoidant personality disorder US Medical PG Question 5: A 30-year-old computer scientist receives negative feedback on a recent project from his senior associate. He is told sternly that he must improve his performance on the next project. Later that day, he yells at his intern, a college student, for not showing enough initiative, though he had voiced only satisfaction with his performance up until this point. Which of the following psychological defense mechanisms is he demonstrating?
- A. Acting out
- B. Countertransference
- C. Projection
- D. Displacement (Correct Answer)
- E. Transference
Avoidant personality disorder Explanation: ***Displacement***
- **Displacement** is a defense mechanism where a person redirects strong emotions, especially negative ones like anger, from the original source to a substitute target that is perceived as less threatening.
- The computer scientist's anger, initially generated by criticism from his senior associate, is redirected to his intern, who is a safer target.
*Acting out*
- **Acting out** involves expressing unconscious emotional conflicts or impulses through behavior, often inappropriate or destructive, rather than through words or feelings.
- While yelling at the intern is a behavior, the primary motive here is redirecting an emotion, not expressing a hidden conflict or impulse without awareness.
*Countertransference*
- **Countertransference** refers to the therapist's emotional reactions to a patient, rooted in their own unresolved conflicts, and is specific to the therapeutic relationship.
- This scenario involves an individual's reaction to workplace stress, not a dynamic within a therapeutic setting.
*Projection*
- **Projection** is attributing one's own unacceptable thoughts, feelings, or impulses to another person.
- In this case, the computer scientist isn't attributing his own poor performance or anger to the intern; rather, he is _redirecting_ his anger.
*Transference*
- **Transference** is the unconscious redirection of feelings and attitudes from a person in the past (e.g., a parent) to a person in the present (e.g., a therapist or boss).
- This scenario involves a direct reaction to a current stressor and redirection of emotion, not the reliving of past relationship dynamics with a new figure.
Avoidant personality disorder US Medical PG Question 6: A 25-year-old woman is brought to the emergency department by her boyfriend after she cut her forearms with a knife. She has had multiple visits to the emergency department in the past few months for self-inflicted wounds. She claims that her boyfriend is the worst person in the world. She and her boyfriend have broken up 20 times in the past 6 months. She says she cut herself not because she wants to kill herself; she feels alone and empty and wants her boyfriend to take care of her. Her boyfriend claims that she is prone to outbursts of physical aggression as well as mood swings. He says that these mood swings last a few hours and vary from states of exuberance and self-confidence to states of self-doubt and melancholy. On examination, the patient appears well-dressed and calm. She has normal speech, thought processes, and thought content. Which of the following is the most likely diagnosis?
- A. Dependent personality disorder
- B. Borderline personality disorder (Correct Answer)
- C. Bipolar II disorder
- D. Cyclothymic disorder
- E. Histrionic personality disorder
Avoidant personality disorder Explanation: ***Borderline personality disorder***
- This patient exhibits characteristic features of **borderline personality disorder**, including **impulsivity** (self-harm), **unstable relationships** (frequent breakups, idealization/devaluation of boyfriend), **affective instability** (rapid mood swings lasting hours), and feelings of **emptiness** and **abandonment**.
- **Self-harm** in BPD is often a coping mechanism for intense emotional pain or a way to elicit care, rather than a genuine suicide attempt, as stated by the patient.
*Dependent personality disorder*
- Characterized by an **excessive need to be cared for**, leading to submissive and clinging behavior and fears of separation, which is not the primary presentation here.
- While there is a desire for care, the prominent features of **impulsivity**, **affective instability**, and **unstable relationships** are not typical of dependent personality disorder.
*Bipolar II disorder*
- Involves episodes of **hypomania** and **major depression**, with mood swings typically lasting for at least **four days** (hypomania) or **two weeks** (major depression), much longer than the hours described here.
- The patient's presentation emphasizes **interpersonal instability** and **self-harm** more than episodic mood disturbances.
*Cyclothymic disorder*
- Involves **numerous periods of hypomanic symptoms** and numerous periods of **depressive symptoms** for at least two years, but these symptoms are less severe than full-blown hypomanic or major depressive episodes.
- The rapid mood shifts within hours and the intensity of **interpersonal dysfunction** and **self-harm** are more indicative of borderline personality disorder.
*Histrionic personality disorder*
- Characterized by **excessive emotionality** and **attention-seeking behavior**, often sexually provocative, and using physical appearance to draw attention.
- While emotionality is present, the **self-harm**, **emptiness**, and **rapid mood shifts** are not core features of histrionic personality disorder.
Avoidant personality disorder US Medical PG Question 7: An 8-year-old boy is brought in by his mother who is concerned about her child’s behavior. She says his teachers have complained about him bullying other students at school, starting fights, and stealing other children’s lunch money. She also says that a neighbor down the street called her 6 months ago and reported that the patient had entered her yard and started viciously kicking her dog. He has no significant past medical history. He is in the 90th percentile for height and weight and has been meeting all developmental milestones. The patient is afebrile and his vital signs are within normal limits. Which of the following adult personality disorders does this patient’s diagnosis most likely predict?
- A. Paranoid personality disorder
- B. Schizotypal personality disorder
- C. Schizoid personality disorder
- D. Avoidant personality disorder
- E. Antisocial personality disorder (Correct Answer)
Avoidant personality disorder Explanation: ***Antisocial personality disorder***
- The patient's presentation with a consistent pattern of violating the rights of others, including **bullying**, **fighting**, **stealing**, and **animal cruelty**, is highly indicative of **conduct disorder**.
- **Conduct disorder** in childhood is the most common precursor to developing **antisocial personality disorder** in adulthood.
*Paranoid personality disorder*
- This disorder is characterized by a pervasive **distrust and suspicion of others**, interpreting their motives as malicious, which is not indicated by the patient's behavior.
- While they may be hostile, their actions typically stem from perceived threats rather than direct aggression or disregard for others' rights as seen here.
*Schizotypal personality disorder*
- Individuals with schizotypal personality disorder exhibit **odd beliefs**, **magical thinking**, and **eccentric behavior** or appearance.
- They also tend to have **social anxiety** and difficulty forming close relationships, which doesn't align with the presented externalizing behaviors.
*Schizoid personality disorder*
- This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- There is no evidence of social withdrawal or uninterest in relationships; instead, the patient is actively engaging in harmful social interactions.
*Avoidant personality disorder*
- This disorder involves extreme **social inhibition**, feelings of inadequacy, and hypersensitivity to **negative evaluation**.
- The patient’s aggressive and non-compliant behaviors are contrary to the withdrawn and fearful nature seen in avoidant personality disorder.
Avoidant personality disorder US Medical PG Question 8: A 24-year-old man comes to the physician with a wound on his forearm. He says that he injured himself by absentmindedly walking into a glass door. He does not have health insurance. He has had 5 jobs in the past 8 months. He quit each job after 3–4 weeks because he found the work beneath him. He was imprisoned 6 years ago for credit card fraud. He was released from prison on parole a year ago. He was expelled from school at the age of 13 years for stealing school property and threatening to assault a teacher. He has fathered 6 children with 4 women. He says that he does not provide child support because he needs the money for his own personal expenses. The patient's vital signs are within normal limits. Examination of the forearm shows a 6 cm long, 0.5 cm deep wound with neat edges on the dorsal surface of the left forearm. There are bruises on the left shoulder, back, and the proximal phalanges of the right hand. On mental status examination, the patient is alert and calm. His mood is described as cheerful. His thought process, thought content, and speech are normal. Which of the following is the most likely diagnosis?
- A. Antisocial personality disorder (Correct Answer)
- B. Intermittent explosive disorder
- C. Oppositional defiant disorder
- D. Narcissistic personality disorder
- E. Conduct disorder
Avoidant personality disorder Explanation: **Antisocial personality disorder**
- The patient exhibits a pervasive pattern of **disregard for and violation of the rights of others**, including impulsive behavior, chronic unemployment, criminal history (**credit card fraud, parole violation**), and lack of remorse for not supporting his children. These behaviors are hallmarks of **antisocial personality disorder**.
- The history of behavioral problems starting at age 13 with **stealing and threatening a teacher** (a pattern consistent with childhood conduct disorder transforming into antisocial personality disorder in adulthood) further supports this diagnosis.
*Intermittent explosive disorder*
- Characterized by recurrent behavioral outbursts representing a failure to control aggressive impulses, often involving verbal aggression or physical aggression toward property, animals, or other individuals.
- While the patient has a history of aggression (threatening a teacher), the primary features in the vignette are more consistent with a pervasive pattern of disregard for others' rights and law-breaking, not solely explosive outbursts.
*Oppositional defiant disorder*
- Characterized by a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months, typically seen in childhood and adolescence.
- The patient's behaviors, such as credit card fraud, chronic unemployment, multiple children with different partners, and lack of child support, extend far beyond just oppositional defiance and involve serious violations of societal norms and laws.
*Narcissistic personality disorder*
- Involves a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy; the patient's statement about work being "beneath him" hints at grandiosity.
- However, the prominent features of **criminality, impulsivity, and disregard for others' rights** are more consistent with antisocial personality disorder than narcissistic personality disorder.
*Conduct disorder*
- This is a diagnostic category for persistent patterns of behavior in childhood and adolescence where the basic rights of others or major age-appropriate societal norms or rules are violated.
- While the patient's history at age 13 (stealing, threatening a teacher) would likely meet criteria for **conduct disorder**, this diagnosis is for individuals under 18. At 24 years old, the adult equivalent is antisocial personality disorder.
Avoidant personality disorder US Medical PG Question 9: A 34-year-old female presents to a counselor at the urging of her parents because they are concerned that she might be depressed. After recently breaking up with her long-term boyfriend, she moved back in with her parents because she could not handle making decisions alone. Soon after their breakup, she started going on 5–7 dates a week. She has been unemployed for 3 years, as her boyfriend took care of all the bills. In the past year, she thought of looking for a job but never felt confident enough to start the process. Her mom arranges her doctor's appointments and handles her car maintenance. She describes feeling uneasy when she is alone. She has hypothyroidism treated with levothyroxine. She does not smoke or drink alcohol. Vital signs are normal. Mental status exam shows a neutral affect. Neurologic examination shows no focal findings. Which of the following is the most likely diagnosis?
- A. Avoidant personality disorder
- B. Histrionic personality disorder
- C. Borderline personality disorder
- D. Separation anxiety disorder
- E. Dependent personality disorder (Correct Answer)
Avoidant personality disorder Explanation: ***Dependent personality disorder***
- The patient exhibits a pervasive and excessive need to be cared for, leading to **submissive and clinging behavior** and fears of separation, as evidenced by her inability to make decisions, reliance on parents, and discomfort when alone.
- Her history of unemployment and reliance on her boyfriend, followed by moving back with parents and having her mom handle appointments and car maintenance, strongly supports an inability to function independently and an excessive need for reassurance and support, characteristic of **dependent personality disorder**.
*Avoidant personality disorder*
- This disorder is characterized by a pervasive pattern of **social inhibition**, feelings of inadequacy, and hypersensitivity to negative evaluation, which are not the primary features here.
- While she may lack confidence in looking for a job, her constant search for new relationships (5-7 dates a week) and reliance on others for decision-making point away from the **social avoidance** central to this diagnosis.
*Histrionic personality disorder*
- This disorder is marked by **excessive emotionality** and **attention-seeking behavior**, often through seductive or provocative means.
- Although she is actively dating, the core issue appears to be her need for care and support rather than a desire to be the center of attention or dramatize her emotions.
*Borderline personality disorder*
- Characterized by a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity, such as **frantic efforts to avoid abandonment** or **recurrent suicidal behavior**.
- While she might fear abandonment (expressed as uneasiness when alone), the overall clinical picture lacks the impulsivity, mood swings, self-harm, or intense anger typically seen in borderline personality disorder.
*Separation anxiety disorder*
- This disorder typically manifests with excessive fear or anxiety concerning separation from attachment figures, often seen in childhood, but can occur in adults.
- While she expresses **uneasiness when alone**, the pervasive pattern of **submissive behavior**, difficulty making decisions, and chronic dependency on others for all aspects of life points more towards a personality disorder rather than an anxiety disorder primarily focused on separation.
Avoidant personality disorder US Medical PG Question 10: A 33-year-old man with documented antisocial personality disorder and substance use disorder is convicted of assault. The defense attorney requests psychiatric testimony that the defendant's personality disorder diminished his capacity to conform his conduct to the law. His history includes multiple prior convictions, repeated lying, failure to sustain employment, lack of remorse, and disregard for others' safety. However, he understood the wrongfulness of his actions and planned the assault in advance. Evaluate the relationship between antisocial personality disorder and criminal responsibility.
- A. Chronic pattern of behavior demonstrates inability to conform conduct to law
- B. Combination of personality disorder and substance use negates criminal responsibility
- C. Comorbid substance use disorder supports insanity defense
- D. Antisocial personality disorder does not meet criteria for insanity defense as patients retain capacity to understand wrongfulness (Correct Answer)
- E. Personality disorders qualify for diminished capacity due to impaired impulse control
Avoidant personality disorder Explanation: ***Antisocial personality disorder does not meet criteria for insanity defense as patients retain capacity to understand wrongfulness***
- In forensic psychiatry, individuals with **antisocial personality disorder** are generally considered criminally responsible because they retain the **cognitive capacity** to distinguish right from wrong.
- The legal system distinguishes between a "cannot conform" (e.g., severe psychosis) and a "will not conform" (personality disorder); since the defendant **planned the assault**, he demonstrated **volitional control**.
*Chronic pattern of behavior demonstrates inability to conform conduct to law*
- A history of repeated legal infractions reflects a **choice to disregard social norms** rather than an organic or psychotic inability to process reality.
- Under most legal standards, inclusive of the **M'Naghten Rule**, a repetitive criminal history does not constitute the "mental disease or defect" required for an **insanity defense**.
*Combination of personality disorder and substance use negates criminal responsibility*
- Combined pathology does not equate to a loss of **mens rea** (guilty mind); substance use is often viewed as **voluntary intoxication**, which rarely excuses criminal acts.
- The presence of these disorders does not inherently impair the defendant's **rational understanding** of the wrongfulness of the specific criminal act.
*Comorbid substance use disorder supports insanity defense*
- **Substance use disorders** are specifically excluded from the definition of "mental disease or defect" in the context of the **insanity defense** in many jurisdictions.
- To qualify for insanity, a condition must typically involve a disconnection from reality, whereas substance use is considered a **behavioral choice** with known legal risks.
*Personality disorders qualify for diminished capacity due to impaired impulse control*
- **Diminished capacity** is a specific legal defense that usually requires a severe mental impairment that prevents the formation of **specific intent**, which is not seen here as the defendant **planned the assault**.
- While patients with personality disorders exhibit **impulsivity**, they still possess the foundational **legal sanity** required to be held responsible for premeditated actions.
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