Thursday, July 28, 2011

The insane are not ‘us’: on normality, psychiatric diagnoses and Norwegian terrorism

After the Oslo bomb and Utøya massacre there is a strong demand of declaring the perpetrator, Anders Behring Breivik, mentally disturbed. Yesterday, the swedish psychiatrist and profiler Ulf Åsgård claimed that Breivik suffers from several personality disorders, among them psychopathy, narcissism, borderline and, notably, obsessive–compulsive personality disorders. This was his judgement after having read a few pages in Breivik's ideological manifesto ‘2083: a european declaration of indepencence’.

The desire to declare Breivik mentally disturbed is quite understandable. He is a tall, blond scandinavian, just like me (well, I'm not that tall, and my hair colour is more like the brown rat, but that is beside the point), but he can't possibly be like me because I would never even think of killing a single person, less massacre young men and women at a youth camp. Following that logic, Breivik can't be normal, since normal people are not mass murderers. He can never be one of ‘us’; he must be insane. (If the perpetrator would have been a muslim, he or she would not have been one of ‘us’ anyway, and the desire to regard him or her as insane, I suspect, not that pressing.)

But what do we mean by ‘normal’? What we consider normal can be judged from at least four points of view. First, the statistical norm defines normality as an interval on a distribution of properties that, at least in theory, can be measured. For example, a person over 2 meters is considered unusually tall. Intelligence is another example: less than 70 points on the Wechler Adult Intelligence Scale (WAIS) is considered that far from the population average of 100 points that it is taken as a indication of mental retardation (in fact, this is the definition of mental retardation according to DSM-IV).

Second, social norms defines what is socially acceptable, and what is not. Social norms are contextual, culturally dependent and varies considerably over the world. Of course, no society allows killing people, at least not of their own kind. However, at war, things are different, and Breivik is at war, at least according to his manifesto.

Third, ideal norms are based on some idea of good health and psychological functioning, for example ‘a state of somplete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946).

Fourth, people that suddenly change in an unpredictable way, although still within statistic, social and ideal norms, are often considered abnormal or at least unusual. Even becoming ‘normal’ can be ‘abnormal’: consider, for example, the psychotic patient that suddenly behaves perfectly normal, or the Alzheimers patient that suddenly remembers everything. This marked change compared to his or her baseline of everyday functioning would certainly be considered abnormal.

Thus, what is ‘normal’ depends on how we see normality. In the case of Anders Behring Breivik, all and none of the above views applies. Of course, he can be a complete lunatic with a severely screwed worldview, emotionally disturbed and without ability of empathy, but he might as well be a consequent, determined man taking the necessary, rational consequences of his political convictions. He killed at least 68 people in cold blood, yes, but even ‘normal’ people do that in war. What is normal depends on the context.

So, is he a narcissistic, obsessive–compulsive psychopath with clear borderline tendencies (or, in other words, completely screwed up), as psychiatrist Ulf Åsgård claims? First, this judgement can not be based on a few pages from his manifesto. It requires meeting Breivik in person, interviewing and observing him. Second, psychiatric diagnoses, and particularly personality disorders, are pretty arbitrary labels of certain behaviour.

Since the 1970:s, when the dominating psychodynamic theories were challenged, psychiatry has worked hard to become a part of medicine and natural sciences. Among other things, this meant revising the diagnostic system (Diagnostic and Statistical Manual of Mental Disorders, DSM) so that it would resemble medical diagnoses. Consequently, all etiology (causes) were removed from the psychiatric diagnoses in the third revision of DSM, published in 1980. Psychiatric diagnoses are merely descriptive.

In this way, psychiatric diagnoses resembles medical diagnoses. A diagnose is a list of symptoms, which, when present, indicates some kind of underlying problem. An inflammation, for example, is a symptom of either an infection or a wound. After finding the correct diagnose, the physician treats the cause of the symptoms, in this case the infection or wound.

An important feature of medical diagnoses is that they are largely decontextualized. It doesn't matter if you broke your leg falling down the stairs or being hit by a car, the symptoms are the same, the leg is still broken and the treatment is the same in both cases.

However, this is hardly true for psychiatric diagnoses. First, since they are only descriptive, there can be no clear cause in a psychiatric diagnose. For example, the symptoms of depression has no equivalent known cause as the symptoms of a broken leg. On the contrary, several different causes can hide between a single diagnose, and the same cause can give rise to different diagnoses. Psychological distress is caracterized by equifinality (different etiologies behind same symptoms) and multifinality (same etiology behind different symptoms).

Even worse, expressions and conceptions of psychological distress differs between cultures. What we know as ‘depression’ in the western world is expressed in rather different ways in other parts of the world. For example, on Sri Lanka, depressed people often report bodily pain, particularly under their feet. This, of course, raises the question if people on Sri Lanka really are depressed? Or the other way round, how do we know that the conglomerate of symptoms we call ‘depression’ is nothing but a culturally dependent expression of psychological suffering?

Personality disorders are defined as ‘an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it’ (DSM-IV), but in reality they are even more fluid than ordinary (so called ‘axis I’) diagnoses. In the end, what qualifies as a personality disorders is what the working groups of the American Psychiatric Association considers being a personality disorder. Thus, the personality disorders have changed over time, with disorders like ‘sadistic personality disorder’ and ‘masochistic personality disorder’ being removed in DSM-IV (1994). It seems that personality disorders will be completely revised in DSM-V, including the very definition of ‘personality disorder’!

So, what can we gain from declaring the terrorist Anders Behring Breivik mentally disturbed or suffering from a severe personality disorders? Nothing much, I'd say. A psychiatric diagnose does not add anything to our understanding of why he did what he did, since psychiatric diagnoses are stripped of all etiology. However, a diagnose frees us of the need to understand; if he is insane, you can't understand anyway. Finally, and most important, if he is insane, he is certainly not one of ‘us’.