"What's the difference between Andres Breivik and the Yorkshire Ripper?"

I know this sounds like the setup of a scurrilous, distasteful joke from Sikipedia, but bear with me; there is a point to this.

I was very interested to hear about Breivik's diagnosis of paranoid schizophrenia and the suggestion from experts that he should be sent to hospital, not prison. I am a Specialist Registrar in Forensic Psychiatry. I regularly deal with people with mental illnesses (including schizophrenia) who have perpetrated serious crimes (including homicide) and often submit recommendations to courts and judges about appropriate placements.

So as a professional, this story is right up my proverbial street.

However, as a blogger, I was more interested in the opinions and comments made about him, and his case on this website, and others.

Now, I must stress I absolutely sympathise with the horrific suffering the loved ones of Beivik's 77 victims must have endured. Clearly, his actions and beliefs are abhorrent. I'm merely examining the situation objectively from a psychiatric perspective.
I'm also making an observation. And that observation is that many people speaking on the internet seem to hold one of three strong beliefs.

1) Of course he is mentally ill, stupid! All murderers, fascists and hate-mongers of this intensity must be.
2) He cannot be diagnosed with paranoid schizophrenia, because he meticulously planned this massacre, and a mentally ill person would not be able to do that.
3) By being sent to hospital, he's been given an "easy option".

1 is not compatible with 2, and 2 and 3 complement each other.
I politely (and I hope not too smugly) dispute all three.

Let's get to the crux of the matter.

What is insanity? What is evil?

Well, one could literally write a library's worth on each topic and still not answer either question.
Being malicious, hateful, and having hurtful, pernicious ideologies, and carrying out atrocious actions by itself is not indicative of mental illness. One could postulate that the subject's personality and character are warped. Sure. The diagnosis of a Personality Disorder could be made. There are many, but a Dis-social Personality Disorder is the most likely, which features include a callous lack of empathy for others and a violation of their rights. A diagnosis of psychopathy could even be made (check out my blog about what psychopaths are like). Personality disorders, by definition are ingrained and on some levels unchangeable. They are not mental illnesses, as the latter must be a change of one's normal mental state.

The vast majority of people who hurt, kill and hate are in control of their thoughts and actions.
Was Breivik?

Psychiatrically, having extreme views or ideas, however bizarre or unpalatable they may be to the rest of us, is not in itself indicative of a delusion. For example, Isaac Newton, stuck a needle into the back of his eye as an experiment. Maybe it was concussion from that apple, yet the man undoubtedly was a certified genius.

Delusions, by definition, are un-understandable, fixed ideas that are out of keeping with one's cultural background, and most importantly they must originate from a false, inexplicable source. He reportedly believed he was chosen (literally, not metaphorically) by a supreme power to decide who has the rights to live or die. This could potentially be a delusion, if the source of this idea was outside the realms of reality - e.g. from aliens, or a message from the television. This is one possible symptom of paranoid schizophrenia. Others include hallucinations (classically, hearing voices) and thought disorder (where one's mind is unable to sustain one topic without jumping to another vaguely related one). Breivik apparently spoke in 'neologisms', the vocal demonstration of thought disorder.

Some people with schizophrenia, especially with a chronic disease that has been under-medicated, may have a low level of functioning, but exceptions do occur. This was sensibly pointed out by Dr Rygnestad, the head of the panel of the Norwegian Board of Forensic Medicine, who reviewed the assessment. It is possible for people with this disorder, as well as other related psychoses such as delusional disorder, to be highly functioning. In theory, it is possible that someone who is psychotic could have the cognitive ability to write detailed manifestos and meticulously plan a massacre like Breivik did. Unusual, but possible. But then again, many things about this case are unusual. With paranoid schizophrenia, killing one person, let alone almost 80, is unusual. The majority of sufferers of schizophrenia are not violent, despite how they are often portrayed. In fact, the risk of self harm is higher than the risk to other people. Additionally, over 90% of violent crime is carried out by people without a history of a psychotic disorder.

Ultimately, I can't really comment with certainty on whether Breivik's diagnosis is correct without assessing him personally. Nobody can. I'm merely trying to keep an open mind. What I would say is that a diagnosis in such a high-profile case would not have been made lightly. I'm sure the forensic psychiatrists involved would have been experienced experts and would have looked at a plethora of other relevant factors, such as family history, previous psychiatric contact, and the presence of the prodrome (a prolonged unusual mental state, that's usually a harbinger of schizophrenia). A frivolous perfunctory conclusion for such a notorious patient, under such scrutiny is potentially career ending.

Given the easy option?

There is no doubt that Breivik will go to a high secure forensic hospital (the Norwegian version of Broadmoor). These can be very tense and dangerous places, that house some very ill people. All too often, assaults, bullying and a hierarchy of status occurs. I am reminded of the case of Peter Bryan, who murdered Richard Loudwell, due to the latter's offence (murdering an 82-year old lady), whilst they were both patients at Broadmoor Hospital.

Of course the ethos of hospital is to treat and rehabilitate. Their ethos of prison is to punish, hopefully rehabilitate. Care vs retribution. Patient vs Prisoner. They may sound different on paper, but in reality the lines are blurred (check out my blog on the criminal code of prisoners). I don't think this is an easy option, as such.

As many bloggers and commentators have pointed out, there is a maximum tariff for Norwegian prisoners, whereas in the psychiatric system, the client is not discharged until it is proven that they risk has decreased. For Breivik, this will be at the educated discretion of the forensic psychiatrists treating him, and is largely influenced by how his symptoms respond to medication and how his ideas and attitudes respond to intense and challenging therapy. If the system over there reflects the English one, my guess would be that he would not be released for several decades, if ever. If he does get leave, it certainly would be extremely gradual, and under heavy supervision.

If I was his doctor (which I'm not), I would want to at least attempt to rehabilitate him. If I was a relative of one of his victims (which I'm even more not), I would want him to suffer. Thinking about it now, I don't know which is right. Neither? Both?

The Yorkshire Ripper, Peter Sutcliffe, was convicted in 1981 for murdering 13 women, and attacking seven others. A confident diagnosis of paranoid schizophrenia was made, but due to the high demand of the public baying for blood, the judge ignored professional opinions of four psychiatrists, and sentenced him as a 'normal person'. He went to prison, against the doctors' recommendations. It seems Breivik probably will not. Sutcliffe's was a political decision, I fear, rather than a medical or logical one. Despite this, he was eventually transferred to Broadmoor Hospital nevertheless, though not before being horrifically attacked and cut across the face.

I'm sure that there is a significant cohort of opinionated people who feel vindicated by Sutcliffe's fate, and share this sentiment about Breivik. The internet is your platform. Feel free to rant abuse towards them. Perhaps you could admonish me for the audacity to question automatic brutality towards these men. If you're struggling to concoct material, please help yourself to any of the following stereotyped responses that I have taken the trouble to write on your behalf:

"I don't need a degree or any of that so-called 'training' to know he must be a raving lunatic."
"The guy is a monster. I hope he rots in hell."
"Bring back hanging."
And my personal favourite: "It is political correctness gone mad."