Extreme Beliefs Mistaken for Psychosis

Editor:

The article, “Anders Breivik: Extreme Beliefs Mistaken for Psychosis,”¹ is a valuable contribution to the confusing question of guilt and culpability of the mentally ill. As the authors point out, the Diagnostic and Statistical Manual of Mental Disorders (DSM) system has failed to provide forensic psychiatrists with the tools necessary to meld biology and law with the philosophical question of free will. As every civilized society since the ancient Greeks has observed, there is such a thing as insanity or mental deficiency that mitigates guilt, even for murder.

The problem of culpability arises when the boundaries of free will are unclear, as in the case of fanatics. Unfortunately, the case of Anders Breivik does not enlighten us regarding the forensic implications of being a fanatic. Recently released information about his childhood^2,3 suggests that he did not just have “extreme beliefs,” but instead had a personality disorder that may be the result of a severely disadvantaged biologic, genetic, and social background, including maternal and grandmaternal paranoid schizophrenia, anoxia at birth, sexual abuse, and severe behavior problems (e.g., torture of animals and bullying other children). Breivik's childhood behavior and symptoms suggest abnormal brain development and function,⁴ but Breivik refused a neurological evaluation.

The original team convened by the court to evaluate him was not permitted to see extensive records that documented his mental illness before age 18. The conclusion of the original expert evaluation team that Breivik suffered from paranoid schizophrenia was later contested by a second panel that diagnosed narcissistic and antisocial personality disorders. Experts involved in a subsequent evaluation diagnosed Asperger's Disorder, Tourette syndrome, and delusional psychosis. Owing to the extreme nature of his crimes, even if he were deemed to be severely mentally ill, there was public demand for life imprisonment. Breivik's extreme beliefs meets the definition of delusion, the core symptom of psychosis. (See Sims⁵ for a scholarly discussion of the distinction.)

Similar unscientific differences are played out in the United States whenever a jury must weigh differences in adversarial opinion reflecting different experience and orientations of the experts. Insanity is a legal concept that should be updated to take into account the myriad causes of reduced guilt, including the effects of fetal alcohol exposure, lead poisoning, hypoglycemia, postencephalitis, posttraumatic stress disorder, chronic traumatic encephalopathy, Alzheimer's, “sleep driving” from prescribed hypnotics, severe child abuse, and many others. Extreme beliefs is a description, not a diagnosis, and it will not facilitate our ability to determine culpability or competence. In fact, the Breivik case illustrates the complexity of inputs into human behavior that cannot be reduced to a simple diagnostic label. The justice system must be informed that mental illnesses that do not fit neatly into DSM-5⁶ may contribute to behavior that requires evaluation and treatment, which is the just and humane course.