Psychiatric Diagnoses Flawed


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.


Clinical Implications

Medscape: What are the clinical implications of your work for practicing psychiatrists?

Dr. Nilsson: I think the recent and rather heated debate over the revision of the DSM clearly illustrated that we are faced with severe diagnostic problems. And it seems to be that this crisis of both clinical and academic psychiatry is encapsulated in the disagreement on the mental state of Breivik. I also think that the historical aspect of our study makes it painfully clear that the so-called operational revolution has not resolved these issues. Ongoing problems with comorbidity and the volatile incident rates of disorders such as ADHD and borderline personality disorder testify to the fact that we still deal with massive validity and reliability issues. Moreover, the hope for the imminent emergence of biomarkers that would ultimately render in-depth clinical psychopathology superfluous has, so far, proved to be a vain one. As it has been pointed out by prominent psychiatrists such as Nancy Andreasen, the net result seems instead to have been a general impoverishment of psychopathological knowledge as the diagnostic manuals have become the sole and undisputed authorities on all things psychopathological.

It seems to me that the only way to safeguard our profession against the reductionist reading matrixes that the DSM-5 or ICD-10 comprise per se is a renewed interest in phenomenological psychopathology. If we are to avoid idiosyncratic diagnostic habits, we need to develop an eye for context and Gestalt. The primary psychiatric object continues to be the disturbed subjectivity -- the experience and expression -- of our patients, and this cannot be exhaustively or adequately accounted for by checklists.

But I also think there is a growing appreciation of this within the psychiatric community. There is an increasing interest in the work done at our facility under the supervision of Prof. Josef Parnas and like-minded colleagues abroad who experience the same thing. I truly think this is the only way forward for a psychiatry that strives for both validity and reliability.

For more information on the work of Dr. Nilsson, please visit the Examination Of Anomalous Self-Experience and University of Copenhagen Center for Subjectivity Research Websites, or  Dr. Nilsson directly. Additionally, Dr. Nilsson and colleagues will present their study at a symposium as part of the upcoming World Congress of Psychiatry in Madrid, Spain.

Original Diagnosis Excluded from Evidence (translated from Norwegian)

The Norwegian psychiatrist, Per Olav Næss, who saw Breivik as a child at 4 years old, said: It is Asperger's syndrome. Næss was not allowed to give evidence in court during Breivik’s trial.... But he spoke out in the media.

Breivik was neat, pedantic, overly clean and systematic. That is how he is described in the report from the National Center for Children and Youth Psychiatry, Norway.

On 3 February 1983, the nearly four-years-old Anders Behring Breivik, his sister and mother were admitted to the family division at the National Center for Children and Youth Psychiatry. The little family was in deep crisis.

Psychiatrist Peter Olav Næss was head of the institution in the 1980s and was responsible for the family.

We did an investigation as a family in crisis and found that care conditions for this young man were not good enough. We recommended that the child had better care conditions. The invitation was not taken into consideration, said Næss to TV 2.

On Friday, 8 June 2012, there was a dispute as to whether Næss should testify in court and tell of the observations he made of Breivik and his family. But Judge Wenche Elizabeth Arntzen decided that confidentiality prevented Næss telling the court about the interaction between himself, four year old Breivik and his mother in the 1980s.

See also: Child psychiatrist not testify in court

The TV 2 announcer read excerpts of the observations made by Breivik as a four year old. He was described as:

"Extremely neat, pedantic. Constantly washes his hands and dries carefully around his mouth. He becomes unsettled when he cannot find adequate organisational systems and is very keen to arrange things nicely next to each other."

And further states:

"He has difficulty expressing himself emotionally, but when it comes to initial reactions, these are strikingly strong."

Asperger’s syndrome (now known as High functioning autism)

In 1983, Næss found that the boy was seriously developmentally delayed in many cognitive and emotional areas.

When Professor Ulrik Fredrik Malt launched the theory that Breivik may have Asperger's syndrome during the trial on that Friday, Næss agreed.

There is a high probability there is a type of pervasive developmental disorder that we call Asperger’s. It excludes the schizophrenia diagnosis, Næss said to NRK.

Breivik does not fall within the common understanding of psychosis in Norwegian forensic psychiatry, as the Norwegian legal system defines it. Therefore he should not receive any unsubstantiated, alternative diagnosis, according to Næss.

In the service of accuracy and justice, the behaviour of Breivik and his interactions with his family was found to be in such a dysfunctional state it was essential for an understanding of the disordered four year old and as a grown man; and should have been presented in court.

See also: Autism Society buzzed by Asperger theory