Delusions and Insanity: The case of Anders Behring Breivik

buying viagra online

ploads/2011/08/breivikheadshot.jpg” alt=”" width=”202″ height=”250″ />Anders Behring Breivik, the individual who went on a gun and bomb rampage in Norway, leaving 76 dead, claims in his 1518-page manifesto that he is the “Justiciar Knight Commander for Knights Templar Europe and one of several leaders of the National and pan-European Patriotic Resistance Movement.” In a previous post, I commented that this belief is where (I believe) the blurred line between extremist beliefs and delusions becomes clear in Breivik’s case. Here, information about delusions and the insanity defense is presented followed by commentary about whether Breivik could successfully mount this defense in Norway.

If, indeed, it can be ascertained that Breivik is not, in fact, a Justiciar Knight Commander for the Knights Templar Europe (never mind whether this organization exists), then it appears as if much of what he has apparently written in the 1518-page manifesto that was released just prior to committing these acts of terrorism is delusional in nature. To be clear, most of what he has written in the manifesto (if indeed we assume that he wrote/compiled the manifesto; a logical assumption that has yet to be verified) is not delusional but can certainly be described as extremist. However, his apparent belief that he belongs to this particular organization (for which no evidence has yet been obtained) appears to be delusional in nature.

Delusions and Insanity

Delusions are beliefs that are clearly false and not based in reality. Delusional individuals cling to these beliefs even in the face of evidence to the contrary. In the United States and Canada, as well as in other countries such as Australia, New Zealand, and the United Kingdom, delusional beliefs can form the basis for an insanity defense wherein the delusional individual is not held criminally accountable for their actions.

Breivik’s attorney has gone on record stating that Breivik could very well have been insane at the time of his crimes. Professor Mike Berry, a Clinical Forensic Psychologist at Manchester Metropolitan University, provides some interesting insight on Breivik in the following clip.

Professor Berry notes that Breivik does not appear to be insane. I agree; however, I wonder how many people who hear this statement might not understand its very specific meaning.

Insanity in the USA & Canada

Insanity is a legal term that refers to the criminal responsibility of an individual. In the USA, most states allow for an insanity defense. The two most common standards for insanity are the M’Naughten Rule and the American Law Institute standard. In essence, these standards require that to be found insane (not criminally responsible for one’s actions) one must not have known what he or she was doing at the time of the crime or, if he or she did know, must not know that it was wrong.

Similarly, in Canada, individuals who were so mentally disordered at the time of the crime as to not know what they were doing or not know that it was wrong can be found Not Criminally Responsible on Account of Mental Disorder (NCRMD), the Canadian equivalent of the insanity defense.

Other countries with adversarial legal systems based on English common law, such as Australia, New Zealand, and the United Kingdom, also allow for severely mentally disordered individuals to present an insanity defense and, if successful, not be held criminally responsible for their actions.

Individuals who successfully present an insanity defense are technically acquitted (found not guilty) of their crimes since they did not have the requisite mental element (intent) for the crime. These individuals most often are detained in a psychiatric facility and treated for their mental disorder. Periodic evaluation of these individuals occurs and they can be released back into the community if a review board or other decision-making authority deems that they are not a threat.

Research shows that it is difficult to present a successful insanity defense. In the United States, this defense is mounted in about 9 of every 1000 felony cases and is successful in only about 2 of those.

More information on the various legal standards for insanity used in the USA and public perceptions of the insanity defense.

Insanity in Norway

Norway also allows for an insanity defense but to meet the requisite criteria for this defense, an individual must have been psychotic at the time of the crime. That is, he or she must have been sufficiently out of contact with reality so as to no longer be in control of his or her own actions. By Breivik’s own account, and by the detailed plan laid out in the 1518-page manifesto, it appears that it would be extremely difficult to argue that Breivik was psychotic and not in control of his actions at the time. In fact, it almost appears to be the exact opposite: Breivik appears to have been acutely and deliberately in control of his actions at the time. As Professor Berry notes in the clip above, Breivik’s level of planning for the attacks was meticulous and painstaking. Over the course of several years he methodically and obsessively planned for these attacks.

Breivik’s View on Criminal Responsibility

The 1518-page manifesto that was released just prior to the attacks delineates a very specific plan for the attacks. Breivik appears to have been very much in control of his actions. In fact, at pages 770-771 of the manifesto, Breivik refers to the criminal responsibility of individuals who commit the acts set out in the manifesto, stating:

Individual Criminal Responsibility:

A person who planned, instigated, ordered, committed or otherwise aided and abetted in the planning, preparation or execution of a crime referred to in the following articles shall be held individually responsible for the crime.

The official position of any accused person, whether as Head of State or Government or as a responsible Government official, shall not relieve such person of criminal responsibility or mitigate punishment.

The fact that any of the acts referred to in the following articles was committed by a subordinate does not relieve his superior of criminal responsibility if he knew or had reason to know that the subordinate was about to commit such acts or had done so and the superior failed to take the necessary and reasonable measures to prevent such acts or to punish the perpetrators thereof.

The fact that an accused person acted pursuant to an order of a Government or of a superior shall not relieve him of criminal responsibility, but may or may not be considered in mitigation of punishment in the future (depending on the accused persons [sic] current and future acts of repent).

Of course, it is unclear whether Breivik was including himself in this reference or whether he would believe in a double standard but it appears that Breivik would consider himself to be criminally responsible for his actions.

Photo courtesy of ibtimes.com

What is Delusional Disorder?

viagra no prescription

alt=”Delusional Disorder” width=”140″ height=”200″ />Delusional Disorder is a psychiatric illness that afflicts a very small percentage of the population. This diagnosis accounts for approximately 1-2% of admissions to inpatient psychiatric facilities. The best estimate for the prevalence of this disorder in the general population is approximately 0.03%. This article describes delusions and Delusional Disorder and the types of delusional themes that can occur.

Delusions

Delusions are beliefs that are clearly false and not based in reality. Delusional beliefs are not accounted for by a person’s intelligence or background and one of the key features of a delusion is the extent to which the person holds firm to this belief, even in the face of disconfirming evidence or proof to the contrary. Delusions can be difficult to distinguish from overvalued ideas, which are unreasonable beliefs to which a person holds but with some level of doubt. Recent research indicates that abrupt onset, implausible content, and relative indifference to the opinions of others may be better distinguishing features for delusions as compared to overvalued ideas. Individuals with delusional beliefs are absolutely convinced that their beliefs are true.

Three criteria for Delusions

In the early 1900s the psychiatrist Karl Jaspers set out three main criteria for a delusional belief:

  1. certainty (the belief is held with absolute conviction);
  2. incorrigibility (the belief is immune to change by compelling counterargument or proof to the contrary); and
  3. impossibility (implausible, patently untrue, or bizarre; simply not based in reality)

Categorization of Delusions

Delusions are categorized as bizarre or nonbizarre and as mood-congruent or mood-neutral.

  • Bizarre delusions are beliefs that are strange and completely implausible, such as having a piece of one’s anatomy removed (when it clearly has not been)
  • Non-Bizarre delusions are beliefs that, although false, are at least possible, such as the person believing that she is being followed or watched
  • Mood-Congruent delusions contain content that are consistent with mood states (depression or mania), such as a depressed person believing that others disapprove of him or a manic person believing that she is a supreme being
  • Mood-neutral delusions are not related to the individual’s emotional state (the beliefs are independent of mood state)

Delusional Themes

Delusional content can come in any variety; however a number of common themes for delusional content have been identified. Examples of some of the most common themes are:

Grandiose Delusions

Delusions that are characterized by fantastical beliefs that one is powerful, famous, omnipotent, or otherwise special.

Delusions of Control

This is a false belief that another person, group of people, or external force controls one’s thoughts, feelings, impulses, or behavior.

Nihilistic Delusions

A delusion whose theme centers on the nonexistence of self or parts of self, others, or the world. A person with this type of delusion may have the false belief that the world is ending.

Delusions of Religiosity

Delusions with religious or spiritual content.

Delusions of Infidelity

A delusion that one’s spouse or lover is having an affair.

Somatic Delusions

Delusions with content pertaining to bodily functioning, bodily sensations, or physical appearance.

Delusions of Guilt

The false feeling of remorse or guilt of delusional intensity.

Delusions of Reference

The false belief that insignificant remarks, events, or objects in one’s environment have personal meaning or significance.

Erotomania

The delusional belief that another person is in love with the deluded person.

Delusional Disorder

The current diagnostic systems used in North America (Diagnostic and Statistical Manual of Mental Disorders; DSM-IV-TR) and Europe (International Classification of Diseases; ICD-10) each recognize delusional disorder as a mental illness.

“The essential feature of Delusional Disorder is the presence of one or more nonbizarre delusions that persist for at least 1 month” (APA, 2000, p.323). Additionally, the individual must not have a symptom presentation that meets Criteria A for Schizophrenia (which means that if the individual also displays prominent auditory or visual hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or so-called negative symptoms, such as flat affect, alogia, avolition, he or she will be diagnosed as having Schizophrenia as opposed to Delusional Disorder).

In addition to having delusional beliefs, the individual must not show any impairment in their functioning and their behavior must not be obviously odd or bizarre, their delusions must not be a result of any mood episodes (depression or mania), and the delusions must not be due to the direct effects of a substance (drugs, alcohol, medication) or a medical condition. Individuals with these symptoms or bizarre delusions are typically diagnosed with having another psychotic disorder, usually Schizophrenia.

The DSM-IV-TR recognizes various types of delusions based on their theme or content (p. 329):

  • Erotomanic: delusions that another person, usually of a higher status, is in love with the individual
  • Grandiose: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
  • Jealous: delusions that the individual’s sexual partner is unfaithful
  • Persecutory: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way
  • Somatic: delusions that the person has some physical defect or general medical condition

Prevalence

Delusional Disorder is relatively rare and accounts for about 1-2% of admissions to inpatient psychiatric facilities. The prevalence rate in the general population has been estimated to be approximately 0.03%, with the lifetime morbidity risk ranging between 0.05% and 0.1%.

Treatment

Delusional Disorder is difficult to treat for a number of reasons, not the least of which is that the individual truly believes that their delusions are true and so are not typically motivated for treatment, with denial being a major obstacle.

There appears to be growing evidence for the effectiveness of various antipsychotic agents in treating Delusional Disorder; however, randomized, controlled trials are still relatively lacking in this area.

Supportive therapies and Cognitive Behavioral Therapy can be helpful for individuals with Delusional Disorder but the vast majority of treatment literature in this area indicates that these types of treatments alone (that is, without accompanying antipsychotic agents) have limited utility for Delusional Disorder.

Professional Resources

Mullen, R., & Linscott, R. J. (2010). A comparison of delusions and overvalued ideas. The Journal of Nervous and Mental Disease, 198, 35-38.

Medscape Reference: Delusional Disorder

Photo courtesy of The American Psychiatric Association

What is Posttraumatic Stress Disorder (PTSD)?

Posttraumatic stress disorder is an anxiety disorder that can develop after an individual is exposed to an extremely traumatic event that involved either direct personal experience of actual or threatened death or serious injury or witnessing an event that involved the death, injury or threat to the physical integrity of another person.

Symptoms of PTSD may develop immediately after a traumatic event or may have a delayed onset, defined as occurring when symptoms begin at least 6 months after the traumatic event.

This article describes the prevalence, risk factors, and symptoms of PTSD.

Prevalence

According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision), the lifetime prevalence for PTSD is approximately 8% of the adult population in the United States (prevalence rates for other countries are not available).

PTSD can occur at any age and can follow a natural disaster, a terrorist event, a war, a rape, a period of prison confinement, or any other potentially traumatic event.

The highest rates of PTSD are found among certain “at-risk” groups, such as survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

Individuals who have recently emigrated from areas of social and civil unrest and conflict may be more likely to have elevated rates of PTSD. In children, the symptoms often manifest themselves in terms of repetitive play and bad dreams and nightmares, in addition to stomachaches and headaches.

Risk Factors

The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are involved. PTSD changes the body’s response to stress and affects an individual’s stress hormones and neurotransmitters. Individuals who have been exposed to trauma in the past may be at an increased risk for developing PTSD.

Social support is an important protective factor against PTSD. In studies of Vietnam veterans, those with strong support systems were less likely to get PTSD than those without social support.

A recent study of PTSD in military personnel shows that pre-deployment psychiatric status is an important predictor of PTSD, with those who screened positive for mental health disorders before deployment being at an increased risk for developing PTSD upon return from deployment. Those who showed signs of PTSD before deployment were almost 5 times more likely to develop PTSD upon their return; those who showed signs of other mental health disorders (such as depression, panic disorder, or an anxiety disorder) were almost 2.5 times more likely to develop PTSD.

Symptoms

The symptoms of PTSD fall into three main categories, including a persistent and disruptive “reliving” of the event, avoidance, and arousal.

Repeated “reliving” of the event, which disturbs day-to-day activity

  • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
  • Recurrent distressing dreams or memories of the event
  • Acting or feeling as if the traumatic event were recurring
  • Flashback episodes, where the event seems to be happening over and over
  • Physical reactions to situations reminiscent of the traumatic event

Avoidance

  • Feelings of detachment or emotional numbing
  • Inability to remember important aspects of the trauma
  • Lack of interest in normal activities
  • Restriction of mood
  • Staying away from places, people, or objects that remind you of the event
  • Sense of having no future

Arousal

  • Difficulty concentrating
  • Difficulty falling or staying asleep
  • Exaggerated startle response
  • Hypervigilance (excess awareness)
  • Irritability or outbursts of anger

Photo courtesy of militaryministry.org

Greater Focus Needed on Prisoner’s Mental Health

One of the hot topics at the recent Forensic Mental Health Conference held at Valkenberg Hospital in Cape Town, South Africa, was the need for a greater focus on prisoner’s mental health. Last year 30 prisoners committed suicide while behind bars in South Africa. The numbers are even greater in the United States. Prison mental health services in many countries are inadequate and in clear need of reform. This article lists some of the suggestions of the World Health Organization for promoting prison mental health services.

To read a brief article about this topic at the Valkenberg Hospital Forensic Mental Health Conference, please click the link below:

http://www.eyewitnessnews.co.za/articleprog.aspx?id=64327

Mental Health in Jails and Prisons

The number of individuals with severe mental illness who are incarcerated in jails and prisons has grown significantly over the last two decades; so much so that prisons may now be the largest providers of mental health services in the United States. That being said, it is still the case that most individuals in need of mental health services in jails and prisons do not receive the care or services that they require. U. S. prisons are neither designed nor equipped for mentally ill prisoners. The ratio of inmates to prison psychologists in the United States has been estimated to be approximately 900:1.

The World Health Organization, in an information sheet on mental health and prisons, noted that prison conditions, in general, are hard on mental health. Overcrowding, violence, lack of privacy, lack of meaningful activities, uncertainly about life after prison, isolation from friends and family, and inadequate health services all contribute to poor mental health in prisoners around the world. The increased risk of suicide in prisons is an unfortunate, but common, manifestation of the cumulative effects of these factors.

The World Health Organization developed the following list of 10 strategies that can be used to increase the detection, prevention, and treatment of mental illness in prisons:

  1. Divert people with mental disorders towards the mental health system
  2. Provide prisoners with access to appropriate mental health treatment and care
  3. Provide access to acute mental health care in psychiatric wards of general hospitals
  4. Ensure the availability of psychosocial support and rationally prescribed psychotropic medication
  5. Provide training to staff
  6. Provide information/education to prisoners and their families on mental health issues
  7. Promote high standards in prison management
  8. Ensure that the needs of prisoners are included in national mental health policies and plans
  9. Promote the adoption of mental health legislation that protects human rights
  10. Encourage inter-sectoral collaboration (bringing relevant Ministries together to collaborate)

For more information on this topic, please see the following resources:

http://www.prisonstudies.org/

The World Health Organization – Mental Health

Standards for Psychology Services in Jails, Prisons, Correctional Facilities, and Agencies

Photo courtesy of eyewitnessnews.co.za

What Types of Mental Health Disorders are most Common among Mentally Disordered Offenders?

Although there are a wide variety of known mental illnesses or mental health disorders, some of these are more prevalent in mentally disordered offenders (MDOs) than others. This article describes the types of mental disorders most commonly implicated in the population of mentally disordered offenders.

To more accurately portray the characteristics of MDOs it is useful to break this population into two segments: those who have been charged with, but not (yet) convicted of, criminal offenses and those who have been convicted of criminal offenses. The first segment of this population would include those individuals for whom legal provisions with respect to mental illness exist, such as competency to stand trial provisions or provisions for the mounting of an insanity defense. The second segment would include those offenders who have a mental illness or mental health disorder of some type and who have been convicted of a criminal offense, the sentence for which may or may not include a period of custody.

MDOs for whom Legal Mental Illness Provisions Exist

The types of mental illnesses or mental health disorders that are most common in this group of offenders tend to be of a more serious, chronic, or acute nature than those of the general correctional population. Legal provisions that deal with the mental state of a defendant, such as competency to stand trial or a criminal responsibility (insanity) defense, are typically reserved for those offenders who have serious, significant mental disorders. Most commonly these types of individuals have mental illnesses that are chronic in nature and that are considered severe. The most common type of mental disorder for this group of offender is Schizophrenia and the other psychotic disorders, including: Schizophreniform Disorder, Schizoaffective Disorder, Delusional Disorder, Psychotic Disorder Due to

a General Medical Condition, Substance Induced Psychotic Disorder, and Psychotic Disorder Not Otherwise Specified.

Although psychosis does not automatically render an individual incompetent (unfit) to stand trial, the psychotic disorders are significantly represented among those who are found incompetent or unfit to stand trial. Similarly, those who are found not guilty by reason of insanity or not criminally responsible on account of mental disorder are significantly more likely to have a psychotic disorder.

Substance use disorders, including diagnoses of both abuse and dependence for a vast array of substances, are far less likely to be implicated in these types of offenders than the general offender population.

Jails, Prisons, and the Correctional Population

The general offender population and the mentally disordered offender population are far more likely to have diagnoses of substance use disorders. That is, substance use disorders are significantly more common in an offender population, including mentally disordered offenders, than they are in the general population. Some research has indicated that nearly 80% of the offenders in jails and prisons have a substance use disorder. This is by far the most prevalent type of disorder among the correctional population.

In addition to substance use disorders, personality disorders, especially Antisocial Personality Disorder, is common in the correctional population. Some estimates indicate that approximately 75% of all offenders in prison meet diagnostic criteria for Antisocial Personality Disorder. In female offender populations, Borderline Personality Disorder tends to be a common diagnosis.

The rates of other mental illnesses or mental health disorders in the offender population tend to be slightly higher in the correctional population than in the general population, with depression, anxiety, and adjustment disorders relatively common in jails and prisons. Of course, the stress involved in being in a custodial setting may also impact some individuals by exacerbating symptoms of mental illness or causing those with serious mental disorders to decompensate or deteriorate.

zp8497586rq