Saturday, July 21, 2012

The mind of a psychopath

The latest What's New Online from the BMJ editor draws attention to the poll on, which asks "Is fanaticism a form of madness?" This is linked to two published articles that debate whether Anders Breivik is sane .

The argument in the Breivik trial is about whether he is psychotic (see previous post in which I suggest there is little doubt that he is not psychotic). That is not to say that he is not psychopathic (mentioned in neither of the BMJ articles). Psychopathy is distinguished from psychosis, although it was originally named "moral insanity". Psychopathic people are not deluded.

And being deluded is not just about whether fanatical ideas are shared by others, which is the argument used by Taylor in his
BMJ article for regarding Breivik as insane. What matters is whether the thinking process that led to the ideas is abnormal - in Karl Jaspers words whether the ideas are "of morbid origin". Jaspers regarded delusional ideas as "ununderstandable", because even putting oneself in the deluded person's position and seeing the world from their point of view, one is still unable to understand how they could hold such a belief with delusional intensity. Obviously there may be a metaphorical sense in which one could understand the thoughts but delusional ideas are believed literally.

Interestingly, the Mental Health Act in England and Wales was amended in 2008 to abolish the distinction between mental illness and psychopathy in terms of the way in which the conditions are regarded under the Act. Because of Breivik's determination not to go to a psychiatric hospital, it could be argued that he is not detainable in psychiatric hospital because he is not treatable (under the old Act) or because there is no appropriate medical treatment available to him (under the amended Act).

Aubrey Lewis (who I've mentioned in another previous post) wrote a Lancet editorial in 1940 on the mind of Hitler. Hitler wasn't deluded. Lewis quoting Oswald Bumke points to the extent to which cold, unfeeling, ruthless, apparently conscienceless, violent, cruel people attain their ends and "how great a role fanatics and other psychopaths play in history and especially the history of revolution". Martyrdom, eg. suicide bombing, may be one outcome of fanaticism. But others, such as Breivik develop the "unshakeable conviction that they are in the right" and end up in a law court. Others play their part on a larger stage, such as Hitler or more modern tyrants.

The real problem with Breivik and Hitler is their personality not mental illness as such. They represent the uglier side of human nature. It is important to recognise this rather than trying to distance ourselves from them by labelling them as insane.


George Dawson, MD, DFAPA said...

"They represent the uglier side of human nature. It is important to recognize this rather than trying to distance ourselves from them by labeling them as insane."

That may be one aspect, but the reason why even delusional people are rarely found not guilty in the US is the overwhelming bias to punish them rather than treat them. I would argue that excluding psychopathy and sociopathy from the legal definitions of mental illness is based on the desire to punish, the lack of viable treatments, and convenience for both mental health professionals and law enforcement.

On the larger issue of fanatacism versus mental illness. There are some studies that look at the personality structure of terrorists and groups of terrorists. The problem is that throughout history humans have a penchant for resorting to homicide in the form of war - sometimes with very little provocation. As long as that is a basic truth of civilization it will be very difficult to define mental illness based on homicidal behavior.

Duncan Double said...

Actually, George, the reason why any reference to psychopathic disorder was taken out of the Mental Health Act was because the politicians wanted psychiatrists to take more responsibility for "psychopaths". There was an argument on the radio between the Home Secretary and the president of the Royal College of Psychiatrists at the time about their treatability. The reform of the Act invented the category of Dangerously Severe Personality Disorder (DSPD) and set up units in some prisons to treat them.

Anonymous said...

Research indicates the old diagnosis of moral insanity is not really comparable to psychopathy now, though both are pretty incoherent mishmashes.

Hitler has been assessed as not meeting criteria for psychopathy as in certain respects he showed stability, social skills, empathy with some, some emotional depth etc.

Breivik was delusionally paranoid, incl. about perceived violent incidents going on around him that weren't, and his thinking and linguistic processes had become abnormal, and his rationalising for why he killed who he did (though he says he had no mandate to kill those categories of traitors, though he wasn't actually part of a group giving him any mandate either way) aren't logically understandable at all unless you only cherry-pick bits that resonate.

Mental illness is not reducible to delusion and so is not separable on that basis from so-called personality disorder.

Schizophrenia at the Schoolgate said...

Hi Duncan

I know this is off-subject, but I wonder if I could send you a review copy of my memoir, 'Surviving Schizophrenia'? I believe it sheds some light on mental health issues as well as being a good read. Here is a link to the book on Amazon, where it has had some excellent reviews:
Thanks for your time

Schizophrenia at the Schoolgate said...

Back to the subject discussed here - I studied law at University, and the more I think recently about the law as it relates to mental health, the more I consider that it needs a total overhaul.

Psychopaths should not be able to shelter behind the 'excuse' of mental illness when they commit atrocities - in my view the issues of violence and mental illness should be formally separated in law. Patrick Cockburn stated the fact clearly in 'Henry's Demons', the book he wrote with his son: 'Violence is not a symptom (of schizophrenia)'.

The issues have become muddled. I recently read about a woman (a 'schizophrenic') who was freed from hospital five years after killing her mother, and sent to live in the community under supervision. She went on to kill another person - really, she was a risk to the public and should have been imprisoned for the same length of time as any murderer, until rehabilitated, not declared 'cured' of her mental health problems and sent out of hospital after such a short time. It was the woman who was the killer, not the 'Schizophrenia'.

In my opinion, people who commit acts of violence should be dealt with as any offender would be, whatever their mental health history. The prisons are already full of the mentally ill in any case (and I have heard that they are treated more compassionately there than in hospital).

As someone who suffered extreme emotional distress (I was sectioned three times) I do understand that mental illness can result in disinhibition, but I still think that violence cannot be excused or explained by the existence of mental illness.