Mass Murder and the Flaws of Checklist Psychiatry

Introduction

Editor's Note: While on-site at the American Psychiatric Association 167th Annual Meeting, held in New York, New York, May 3-7, 2014, Medscape interviewed Lars Siersbæk Nilsson, MD, of Psychiatric Centre Hvidovre at the University of Copenhagen about his study^[1] on how conflicting psychiatric evaluations of Anders Behring Breivik, who in 2011 committed a horrific act of mass murder in Norway, reflects flaws in psychiatric diagnosis.

Medscape: Can you give us some background on your study?

Dr. Nilsson: It came, of course, as a huge shock to otherwise peaceful Scandinavia when Anders Behring Breivik killed 77 civilians in a 2-fold attack on downtown Oslo and the island of Utøya, Norway, in 2011. But from a psychiatric point of view, another shock followed in the wake of this immense tragedy when it became clear that the 2 forensic psychiatric reports that were drawn up directly contradicted each other. Whereas the first one gave him a diagnosis of paranoid schizophrenia, the second evaluation firmly rebutted this and instead diagnosed him with a narcissistic personality disorder with antisocial traits.

Now, such a fundamental disagreement seems to be an obvious problem to our profession. It seems to question the very legitimacy of psychiatry as a scientific discipline, and clearly it remained unresolved by any recourse to operational criteria, so we decided to examine it in further detail. What then immediately became clear was that this was not a novel problem. In fact, psychiatry struggled with the very same issues in 19th century France when a young peasant by the name of Pierre Rivière killed most of his family. While some doctors saw only an evil constitution, others -- including the renowned Esquirol -- drew attention to his peculiar convictions and bizarre behavior, deeming them the hallmark of insanity.

So across almost 2 centuries and the huge strides made by neurobiology and the cognitive sciences, it seems that psychiatry is still faced with the same basic and very pressing challenges -- namely those that have to do with our diagnostic praxis. Thus it was the wish to clarify the nature of this fundamental problem that drove our study. Using the case of Rivière as a perspectival backdrop, we then carried out a phenomenological comparative reading of the 2 psychiatric reports on Breivik that had been leaked to the press.

Medscape: What were the results of your study, and what do you believe the reasons are for the differing psychiatric profiles of Breivik and Rivière?

Dr. Nilsson: Michel Foucault and others deal with the case of Rivière in their 1975 book I, Pierre Rivière, Having Slaughtered My Mother, My Sister, and My Brother. Among other things, they interestingly describe how a sort of grille de lecture is at the heart of the diagnostic disagreement. This reading matrix is, for one thing, influenced by the level of conceptual knowledge of the examiner. For instance, the local GP who deemed Rivière compos mentis simply lacked the knowledge to incorporate the observations that had a bizarre quality to them into a meaningful psychopathological whole -- and thus they are not even mentioned. So while Foucault and his collaborators by no means conclude that he was insane, they do stress that this sorting of information serves to set up a coding system for the interpretation of the rest of the reported facts. The implications are, of course, that we no longer deal with 2 differing yet neutral case descriptions but rather the painting of 2 different portraits.

And seeing how striking omissions were made, especially in the second psychiatric evaluation of Breivik, I think it becomes clear that something similar is at play here. For instance, the bizarre behavior described by his mother in the first report is not mentioned; in fact she is not even interviewed. Nor is the flawed nature of the planning of the attacks mentioned. It remains, for example, unsaid that his supposedly shrewd cover stories designed to keep him from being apprehended by the police have him posing as an eccentric gold-digger and soldier of fortune preparing to masquerade as a police officer at a costume party.

This then allows phenomena that are otherwise described more or less identically in the 2 reports to be interpreted in radically different ways. Thus, Breivik's growing concern of getting infected -- which leads him to wear a mask at home, accuse his mother of talking to too many potentially infectious people, and take all of his meals in the privacy of his own room -- is no longer seen as delusional. It is merely a question of exaggerated caution or possibly hypochondria but with no psychotic quality to it. Similarly, the made-up words that Breivik frequently uses are no longer thought of as neologisms and thus reflective of formal thought disorder. According to the second evaluation, they are simply ordinary combinations of words and as such are viewed as an integral part of any dynamic language. So while we obviously could not presume to diagnose him in any way, we definitely can say that information is being selected among the reports and that this seems to be foundational to the diagnostic disagreement.

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