Medscape has a brief interview with Lars Siersbæk Nilsson, MD,
a psychiatrist who was a lead author on a poster that was presented
earlier this year at the annual meeting of the American Psychiatric
Association (the "other" APA or APAo if I may be allowed). The
interview and the poster presentation was concerned with psychiatric
diagnosis of Anders Behring Breivik, the Norwegian mass murderer
who killed a total of 77 people, eight from bombing a government
building in Oslo and 69 teenagers and adults at a camp on the island
of Utoya (for more detail, see the Wikipedia entry at:
http://en.wikipedia.org/wiki/Anders_Behring_Breivik
There are a couple of points made by Nilsson concerning Breivik:
(1) There were two forensic psychiatrists who examined Breivik
and they reached different diagnostic conclusions: one diagnosed
him with paranoid schizophrenia while the other diagnosed him
with narcissistic personality disorder with antisocial traits. It
is important to stress that the two psychiatrists apparently examined
Breivik separately and did not follow the same "script", that is,
one asked about certain issues while the other did not. Given
that the information "extraction" process was not uniform, it
probably should not be surprising that there was a difference in
diagnosis because the two psychiatrists were not using the
same information -- it would have been more disturbing if both
followed the same structured interview and reached different
diagnoses (though this too can happen depending upon on the
reliability and validity of the instrument being used). Nonetheless,
it is surprising that there was such a difference in diagnosis and
Nilsson and colleagues take this as indicating the current problems
with methods of evaluating psychopathology and reaching a diagnosis.
Medscape requires one to register to use their website so if you
want to read the interview with Nilsson you might be prompted
to register if you want to read the article; the article might be
reachable at:
http://www.medscape.com/viewarticle/825800_print
The poster that serves as the basis for the interview had its abstract
published in the journal "Schizophrenia Research" and a PDF
containing the program abstract is available IF your institution has
a subscription to the journal. Here is the reference for the abstract:
in the journal:
Poster #T171 PIERRE RIVIÈRE VS. ANDERS BREIVIK: IS HISTORY
REPEATING ITSELF? RATIONALITY, MADNESS, AND PSYCHOPATHOLOGY
IN THE 19TH AND 21ST CENTURY
Nilsson, Lars Siersbæk et al.
Schizophrenia Research , Volume 153 , S350
Here is where you can access the abstract on the SR website but you'll
be prompted for login info:
http://www.schres-journal.com/article/S0920-9964%2814%2970987-9/abstract
(2) What is original with Nilsson's poster and discussion is the
comparison
made between the diagnoses made of Anders Breivik and the diagnoses
made nearly 200 years earlier for a mass murdered named Pierre Riviere.
I admit to not being familiar with Riviere even though the (in)famous
Michel
Foucault had edited a book on Riviere that was part autobiographical
material by Riviere and part Foucault providing context and
interpretation.
The title of the book is: "I, Pierre Rivière, Having Slaughtered My
Mother, My Sister, and My Brother." Parts of the book is available on
books.google.com; see:
http://books.google.com/books?id=5uRVWs6kbiYC&printsec=frontcover&dq=%E2%80%9CI,+Pierre+Rivi%C3%A8re,+having+slaughtered+my+mother,+my+sister+and+my+brother+.+.+.+A+case+of+parricide+in+the+19th+century%E2%80%9D&hl=en&sa=X&ei=17yXU-ubCMG-sQSzgIKgAw&ved=0CB4Q6AEwAA#v=onepage&q=%E2%80%9CI%2C%20Pierre%20Rivi%C3%A8re%2C%20having%20slaughtered%20my%20mother%2C%20my%20sister%20and%20my%20brother%20.%20.%20.%20A%20case%20of%20parricide%20in%20the%2019th%20century%E2%80%9D&f=false
as well as on Amazon:
http://www.amazon.com/Pierre-Riviere-having-slaughtered-brother/dp/0803268572
The book was published in 1975 and the NY Times has a review of it which
is available here:
http://www.nytimes.com/books/00/12/17/specials/foucault-pierre.html
The question presented by Riviere was what prompted him to commit the
murders: was it a "rational" act (any film noir fans will understand
this in the
context of such movies as "Double Indemnity" and "The Postman Always
Rings Twice"), was it "insanity", or was it demonic possession or
something
similar (the latter diagnosis is rarely used these days but not
completely
gone). Of course, there was disagreement about the actual reasons for
why
the acts were committed though not that the acts had been committed. The
key issue is whether there were "extenuating circumstances" that may
have
"excused" the actions and which would have suggested that instead of
punishment,
the perpetrator be treated for his condition (i.e., by whatever passed
for
psychiatric treatment at that time or exorcism).
Nilsson wants to draw a parallel between the psychiatric disagreement
over
Breivik with the disagreement over the "diagnosis" of Riviere, that is,
after
nearly 200 years, psychiatrists still cannot come up with a reliable and
valid
diagnosis even for one of the most heinous crimes that a person can
commit.
Nilsson faults the current methods (checklists of symptoms do not do the
job,
especially if the evaluators do not focus on the same criteria) and the
failure
of operationalization and other problem with the DSMs and ICDs (choose
your
favorite problem with these diagnostic bibles). He urges a more
subjective
examination of the person who has committed the crime, what is his/her
phenomenology and what is the "gestalt" in which the actions occurred.
I will leave it to the clinicians to examine these issues but teachers
of psychology
may find it relevant to their coverage of certain topics. Use it with
caution.
Finally, the classic film by Akira Kurosawa "Rashomon" tells the tale of
a
crime: an apparent murder (but is it really murder?) and a rape. One
traditional interpretation of the film is that everyone has their own
perception
of what happened in an event and, perhaps more importantly from a
dramatic
perspective, the self-serving bias to present oneself in the most
positive
or sympathetic light -- even in death. Of course, Kurosawa finesses the
fundamental issue: one can view this film as police procedural (the
evidence about what had happened is given before a magistrate) and
the ultimately the "justice system" must decide what actually happened
and who must be punished but Kurosawa never deals with these issues.
One is left to wonder what did the legal authorities finally decide
given the
discrepancies in the testimonies -- and decide they must because you
don't want any open cases. For a counter weight to "Rashomon", I
suggest
watching Yoshitaro Nomura's "Zero Focus" which covers similar ground
but is more pragmatic in how it deals with discrepancies; available at
Amazon; see:
http://www.amazon.com/Zero-Focus-Yoshiko-Kuga/dp/B0002KPHU6/ref=sr_1_1?s=movies-tv&ie=UTF8&qid=1402456792&sr=1-1&keywords=zero+focus
The point is regardless of whether psychiatrists agree in their
diagnosis or
not, pragmatically, something has to done with the perpetrator. In the
case of Riviere, the answer is simple: he was put into solitary
confinement
and ultimately hanged himself. Of course, today we are much more
sophisticated and we won't let Brevik have shoe laces or belts or other
implements that he could use to end his life (it is unclear that he has
any
desire to do so). Instead, we will keep him on ice while we work out
how to come up a consensus opinion about what is wrong with him (if
anything) and what is the most appropriate course of action.
Psychiatrists
and clinical psychologists (using the nifty tools we're developed in
neuroscience and cognitive science) will have to make a rational and
principled decision and be able to articulate the framework to follow
for those who have to confront such tragedies in the future.
-Mike Palij
New York University
m...@nyu.edu
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