Assessing Homicidal Mental States at the Time of Offense II: The 2011 Norway Massacre: The 1st forensic psychiatric examination.

The first examination conducted by two psychiatrists included 13 interviews (36 hours total), review of police interrogations, and collateral interview with Breivik’s mother. They coded the material using the Norwegian version of the Mini-International Neuropsychiatric Interview Plus for ICD-10, and selected modules of the Norwegian version of the Structured Clinical Interview for DSM-IV (SCID-IV). Based on criteria for both instruments, they determined that Breivik was a paranoid schizophrenic and was psychotic at the time of the offenses. He was therefore legally insane. Their rationale for their opinion was both interesting and controversial in the public and professional community.

Was Breivik psychotic or a grandiose, right wing extremist? How does one clinically distinguish the ideologically colored rants of a schizophrenic from a radicalized right wing extremist extremist?

The basis for the paranoid schizophrenia diagnosis included the following findings: Breivik’s published political concerns and his view of himself as a resurgent Knight Templar saving society from the influx of Muslims were viewed as grandiose delusions with bizarre and paranoid qualities. “…they did not consider him psychotic by mistaking his extremist, racist, right-wing views as delusional, but because they thought he had grandiose delusions regarding his own role in this extremist universe” (Mele, 2013, p. 18). “There was general agreement among all psychiatrists who evaluated him that his writings lacked any evidence of the formal thought disorder displayed by many individuals with schizophrenia” (Roth & Dager, 2014, p. 182.). Further, “…his ideas were not so original or bizarre as to be labeled delusional when considered in the context of contemporary political extremism” (p. 182). Breivik’s writings “reads much like fantasy fiction, with the plot, characters, and props taken from World of Warcraft and freemasonry…” (p. 182).

The examiners viewed his stilted language and flat/inappropriate affect as additional indicators of paranoid schizophrenia. They ruled out delusional disorder. Of interest is the fact that Breivik demonstrated no Schneiderian first rank symptoms. He had no history of mania, depression, auditory hallucinations, or ideas of reference.

Just a reminder: Schneiderian first rank symptoms include:

Auditory hallucinations
• Hearing voices conversing with one another
• Voices heard commenting on one’s actions (hallucination of running commentary)
• Thought echo (a form of auditory hallucination in which the patient hears his/her thoughts spoken aloud)
• Somatic hallucinations
• Delusions of control / of being controlled)
• Thought withdrawal
• Thought insertion
• Thought broadcasting (also called thought diffusion)
• Delusional perception

Next: the second forensic psychiatric examination.

Roth, W., & Dager, S. (2014). Psychiatry on Trial: The Norway 2011 Massacre. The Journal of Nervous and Mental Disease, 202, 3, 181-185.


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