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Head To Head Maudsley Debate

Do cases like that of Anders Breivik show that fanaticism is a form of madness? No

BMJ 2012; 345 doi: (Published 11 July 2012) Cite this as: BMJ 2012;345:e4647

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Re: Do cases like that of Anders Breivik show that fanaticism is a form of madness? No

I find myself accepting the gist of Professor Taylor's arguments. Perhaps it is not helpful to conflate - as I think Professor Fahy does - psychiatric diagnosis, the useful ideas about responsibility which operate in the practice of law, and their wider common use in language and religious belief, feelings of injustice if certain behaviour is not punished, and speculative or corruptive effects on society of categorising some behaviours or mental states as illnesses.

The task of psychiatrists is to attempt to devise psychiatric diagnoses relating to mental morbidity with universal and agreed validity, and to be able to give useful opinions on the natural history of any condition without treatment, and the options for treatment and their likely outcomes. We have to accept that our current language, including biological language, is too imprecise and too limited to adequately achieve more than approximations.. While there are critics who actually deride the results of this endeavour so far, both within psychiatry and in associated professions - some of whom are undoubtedly cranky or, dare one say, fuelled with a tinge of fanaticism - no better system has yet been presented , and we have to persevere as objectively as possible, irrespective of any effects on 'the law' or society.

The law is just that 'the law' - as devised by humans at a particular time - it does not necessarily take into account all scientific or other facts or concepts of balance and justice, particularly in our adversarial system. It does not simply accept the advice of a specialist that someone suffers from paranoid schizophrenia and can therefore act in a logical way but on the basis of delusional perceptions - this rightly has to be spelled out in as clear a description as possible - but we all know that this is difficult when the audience (jury and judge) have limited if any l experience of personal and prolonged interaction with individuals suffering psychosis. On this point while I agree with Professor Fahy that many people with schizophrenia do deteriorate cognitively, I would be surprised if that is often the case with the paranoid variant where individuals seem to retain, at least in their early years, unblunted conversational skills and also sharp cognitive abilities including those required for elaborate planning.

'Responsibility' is a tricky issue given the contortions of the legal definition in the McNaughton case, but is not in general a remit for psychiatrists, but one for the court - psychiatrists are best limited to an opinion on 'disposal' on the basis of the possibilities for treatment., especially since a sizeable body of psychiatrists, psychologists, philosophers and others consider 'free will' an illusion and therefore issues of responsibility problematic. However in practice that view is not incompatible with the pragmatic approach of the law, which deems (whether or not this is true in a real sense) we are responsible for our actions, and by doing so can manipulate our behaviour, and also allow for reduced responsibility where brain function is seen to be compromised and adversely affecting a person's pre-morbid personality.. This is rather unfair on those with psychopathic personalities who fall foul of the law, but there is no easy way round that.

If a psychiatric diagnosis has validity it must in general be universally recognised allowing for the fact that less fundamental aspects are derived from cultural differences. At its simplest we may say 'there's something wrong (mentally) with that chap' because of the behaviour he exhibits but our concern is whether that is associated with clinical morbidity or not - in the same way as other branches of medicine. Psychiatric morbidity may indeed be absent in the average football fanatic, but one may surmise is more likely in someone like Brevik on the basis of third party reports - but only those in possession of the facts and personal knowledge of him can reasonably present an authoritative opinion, because the human computer still beats any description posed in language..

Competing interests: No competing interests

17 July 2012
David M Bowker
Retired Consultant Psychiatrist