In 2011 Anders Behring Breivik, ABB, slaughtered 77 civilians in a twofold attack in Oslo and on the island of Utøya, Norway. During his trial ABB’s sanity or lack thereof was fiercely contested. Two psychiatric evaluations arrived at radically different diagnoses of psychosis and personality disorder respectively. Though unrivalled in its bestiality, the case of ABB is not unique. In 1835, a French peasant Pierre Marie Rivière, PMR, in a seemingly incomprehensible act of cruelty killed his immediate family. Some contemporaries, including Esquirol, saw in PMR the traces of radical irrationality (psychosis) while others ascribed his deeds to an evil personality.
Thus a basic disagreement on the nature of rationality and madness appears to have persisted across the centuries. The aim of this paper is to clarify the sources of this diagnostic divergence and to shed some light on pressing epistemological and clinical issues related to the diagnostic process, its conceptual foundation and the question of differential diagnosis.
A 1975 book by Foucault et al. contains a manuscript by PMR detailing the background for his actions and extracts from the legal and psychiatric documents pertaining to the case. During the trial of ABB the two psychiatric evaluations were leaked to the press and made available online.
In both cases the assessors had access to a very similar body of information from which the elements were selected that seemed to support their diagnostic conclusion. This selectivity led to widely different interpretations of the seemingly identical source psychopathological phenomena. The potential for a diagnostic disagreement in psychiatry has remained unresolved by the neuroscientific advances of the intervening years and, indeed, by the use of the so-called “operational” criteria.
The diagnostic process always involves a selection among the body of the available “objective” data. This selection process is prefigured by the diagnostician’s conceptual template that structures her cognitive field and thereby renders some information relevant and excludes other as irrelevant. Moreover, the conceptual template influences the psychopathological significance of the clinical presentation. The operations of the conceptual templates or grids of prototype hierarchy are constituted by the examiner’s knowledge and experience, ethical and other personal inclinations, and a host of other factors. Such cognitive constraints on the diagnostic process, already described by Jaspers, cannot be eliminated by the so-called “operational” diagnostic systems.
In the case of PMR, the major source of the diagnostic disagreement could be traced to the different levels of professionalism of the involved examiners. In the case of ABB, a nearly procrustean adherence to the ICD 10 criteria (which were not immune to different interpretations) was at the heart of the diagnostic disagreement and seemed to invite private psychological interpretations. The diagnostic disagreement in the case of ABB seems to disclose some serious because fundamental epistemological weaknesses of the ICD-10, notably an absence of a prototypical grid that is needed to structure the psychiatrist’s cognitive field and an impossibility of adequate description and definition of the psychopathological phenomena (symptoms and signs) through the so-called “operational criteria”, i.e. brief, simple, lay language statements. Defining the diagnostic classes by a specific number of seemingly mutually independent features, and without any emphasis on the phenomenological typicality or structure of both the diagnostic class and its constituents, is likely to entail diagnostic distortions. Finally, it is suggested that in terms of diagnosis, the notion of the schizophrenia spectrum appears as being highly relevant in both cases.