Forensic psychiatric statement -- Anders Behring Breivik (X)

Christian Skaug

pre­vious

7. SUMMARY

The sub­ject is now a 32 year-old man. He was born in Oslo XXXXX XXXXX.

[…]

His parents had pre­viously been mar­ried, and both had child­ren from pre­vious rela­tion­ships. The subject’s parents are both alive. XXXXX XXXXX. His mot­her lives alone in Oslo. The sub­ject has three half- siblings, the six years older XXXXX on his mother’s side and XXXXX who is between eight and twelve years older than sub­ject on the father’s side.

[…]

There is no infor­ma­tion about serious finan­cial dif­fi­cul­ties or sub­stance abuse pro­blems in the subject’s family.

The subject’s parents divor­ced when he was eigh­teen mon­ths old, and he moved back to Frog­ner in Oslo with his mot­her and half sis­ter XXXXX.

After the divorce, the sub­ject has never lived per­ma­nently with his fat­her. His fat­her moved to XXXXX and the sub­ject visited him there in the period from he was six to 14 years old. After this, the con­tact with his fat­her was less fre­quent, and after the sub­ject tur­ned 16, there was little con­tact between them. The sub­ject has not had any con­tact with his fat­her after the age of 22

When the sub­ject was three years old, his mot­her con­tacted the local social ser­vices to apply for a week­end home for the sub­ject. The rea­son was that the mot­her found the sub­ject deman­ding. This was tried, but did not work, and the arran­ge­ment ended.

In 1983, when the sub­ject was four years old, mot­her con­tacted the local family coun­se­ling office, and the family was referred to the then State Cen­ter for Child and Youth Psychia­try (SSBU).The family was admit­ted there over a period of about a month in 1983.

[…]

The other facts of the case have not pro­vi­ded any evi­dence of serious psycho­pat­ho­logy in any of his rela­ti­ves, XXXXX XXXXX. There is no infor­ma­tion regar­ding anyone in the family about serious men­tal health pro­blems requi­ring hos­pi­ta­liza­tion or assi­stance from spec­ia­lists. There is no infor­ma­tion about family mem­bers, on the father’s or mother’s side, having ended their lives by suicide.

[…]

The family was con­side­red in need of help. It was sug­ge­sted that the sub­ject were placed in fos­ter care, but this never happened.

The same year, his fat­her petitio­ned to trans­fer custody and gene­ral care for the sub­ject. The case was brought to court and it was deter­mined that the mot­her should con­ti­nue to have custody of the sub­ject, while furt­her investi­ga­tion was to be done. In the mean­time, his fat­her wai­ved his claim for custody and the mat­ter came to a settlement.

In 1984, an investi­ga­tion case was ope­ned in the home, based on SSBU’s expres­sion of con­cern. After investi­ga­tion, no basis was found for fos­ter care place­ment. The case was brought before the Child Wel­fare Com­mittee, where it was dismissed.

Three or four years old, the sub­ject star­ted going to kin­der­g­ar­ten. He adap­ted well, had fri­ends, and not­hing con­spi­cuous is reported as to his moto­ric, psycho­lo­gical or edu­ca­tio­nal development.

I 1982, the sub­ject, his mot­her and half sis­ter moved to a new, five-room apart­ment at Skøyen in Oslo. The sub­ject star­ted atten­ding Smed­stad ele­men­tary school at the nor­mal age. He com­pleted ele­men­tary school and there is no infor­ma­tion about social, beha­vioral or lear­ning dif­fi­cul­ties. He got on well aca­de­mically and at no time custo­mized trai­ning, assess­ment or spec­ial assi­stance was discus­sed or implemented.

The sub­ject then com­pleted Ris Junior High School. Nor from this period is there any infor­ma­tion that the subject’s func­tioning at school was con­spi­cuous in terms of lear­ning, social or beha­vioral mat­ters. In 1994, the family moved to a smal­ler apart­ment, also at Skøyen in Oslo.

[…]

At the end of 1994, the Child Wel­fare Ser­vices rece­i­ved a mes­sage that the sub­ject had been arrested by the police and reported for tag­ging. A sur­vey case was ope­ned and discus­sions held with the family. After a few mon­ths, the case was ended wit­hout any assi­stance measures.

The sub­ject then went to Hart­vig Nis­sen upper secondary school. He com­pleted the first year success­fully. He then changed school to Oslo Han­dels­gym­na­sium, where he success­fully com­pleted the second year. There is no infor­ma­tion about lack of social or beha­vioral func­tion from this period. He drop­ped {1out of school by Chris­t­mas in third grade, after which he has never com­men­ced or com­pleted any for­mal education.

After he left school, the sub­ject star­ted his own com­pany, nego­tia­ting telep­hone sub­scrip­tions. He tried inves­ting in the stock mar­ket, but lost a large amount of money on options. He also had shor­ter and lon­ger emp­loy­ment con­tracts in seve­ral com­pa­nies doing tele­mar­ke­ting and custo­mer support.

The sub­ject moved out from home in 2001.He lived for a year in a com­mune XXXXX XXXXX in Oslo. From 2002 to 2006, he lived alone in a rented apart­ment in XXXXXXX. Since 1999, the sub­ject has been enga­ged in various busi­ness acti­vities as an inde­pen­dent self-employed. There is infor­ma­tion that the busi­ness of one of the com­pa­nies was based on the pro­duc­tion of all kinds of false diplo­mas. He also sold space for out­door billboards and sold a variety of ser­vices wit­hin the IT busi­ness. The subject’s dif­fe­rent com­pa­nies were gra­dually clo­sed down, and the last one went bank­rupt in 2006/2007.

In 2006, the subject’s mot­her offe­red him to move home with her in XXXXX XXXXX, which he did. Sub­se­quently, he has never been involved in any acti­vities, neit­her as self-employed nor as an emp­loyee. He has not had any income or rece­i­ved any sup­port from pub­lic agen­cies. The sub­ject wit­hd­rew from social con­tact with fri­ends, and has until the cri­mi­nal actions mostly stayed in his own room. His mot­her cle­aned the house, washed his clot­hes, shop­ped and cooked for him.

The sub­ject lived with his mot­her until May 2011, when he moved to a rented farm in the val­ley Østerdalen.

The sub­ject has no known abuse of alco­hol, addic­tive drugs or illi­cit drugs. He con­firms having smoked mari­juana on a few occa­sions. In three periods of a few mon­ths’ dura­tion, he has taken ana­bo­lic ste­roids. The last period las­ted until the cri­mi­nal actions.

The sub­ject is now char­ged as detai­led in the statement’s ope­ning chap­ter. The sub­ject has shown psycho­tic sym­p­toms during the investigation.

8.DISCUSSION/ASSESSMENT

8.1 INTRODUCTION:

The experts’ assess­ment is based on the case docu­ments, inclu­ding a lar­ger num­ber of inter­ro­ga­tions on DVD/CD, infor­ma­tion obtai­ned from per­sons who know the sub­ject, col­lected health data, psycho­met­rics and the experts’ own con­ver­sa­tions with the subject.

To under­stand the terms of the assess­ment, one must read the descrip­tive parts of the state­ment. This applies both to the docu­ment excerpts (inclu­ding the assess­ment of the subject’s com­pen­dium) and the experts’ con­ver­sa­tions with the subject.

After the min­utes of each con­ver­sa­tion in the statement’s Chap­ter 5, a psychiatric pre­sent sta­tus is given that pre­sents the experts’ sum­mary and assess­ment of the sym­ptom pic­ture descri­bed through the cur­rent con­ver­sa­tion. In the following dia­gno­s­tic assess­ment chap­ter, ​​a sum­mary of the experts’ fin­dings is made in a final dia­gno­s­tic conclusion.

The assess­ment is pre­sented chro­no­lo­gically, with a review of the subject’s life, both in terms of sym­ptom devel­op­ment and functioning.

8.2 DIAGNOSTIC EVALUATION

Through the case docu­ments and the con­ver­sa­tions with the subject’s mot­her, infor­ma­tion is obtai­ned that the sub­ject evolved incon­spi­cuously with respect to moto­ric and ver­bal skills throug­hout his first years of life.

Star­ting from 1981, the sub­ject and his family were in con­tact with the local child wel­fare ser­vices. At that time, the sub­ject was descri­bed by his mot­her as deman­ding. No infor­ma­tion emer­ges through this con­tact about spec­i­fic psycho­pat­ho­logy in the subject.

The sub­ject and his family stayed at the Natio­nal Cen­ter for Child and Ado­le­scent Psychia­try in the period from 1 February 1983 to 25 February 1983.In the disch­arge sum­mary from the stay, inte­rac­tion dif­fi­cul­ties with the mot­her are descri­bed. There is no infor­ma­tion about spec­i­fic psycho­pat­ho­logy in the subject.

In a let­ter to the child care ser­vices after the same stay, the sub­ject is descri­bed as avo­id­ing con­tact, a pas­sive and little anxious child, with a manic defense cha­rac­te­rized by rest­less acti­vity and a fake, depreca­ting smile. In the let­ter to the local child wel­fare ser­vices, there is no dia­gno­sis associa­ted with the subject’s men­tal health, and no spec­i­fic descrip­tion of any other psychopathology.

Through con­ver­sa­tions with the sub­ject and with his mot­her, as well as through the additio­nal infor­ma­tion obtai­ned, the experts have not found evi­dence measu­res have been imple­men­ted that during the subject’s upbrin­ging related to his beha­vior, his intel­lec­tual devel­op­ment, or his men­tal func­tioning. There is no infor­ma­tion to indi­cate that there has been any con­cern related to his devel­op­ment until puberty.

When the sub­ject was 15 years old, in 1994-1995, the local child care ser­vices again ope­ned a case regar­ding the sub­ject and his family. The back­ground was that the sub­ject during the course of 1994 on seve­ral occa­sions was reported to the police for graffiti/vandalism. After con­ver­sa­tions with the sub­ject and his mot­her, the case was not found to be severe enough to imple­ment assi­stance measu­res. In the case docu­ments from the child wel­fare ser­vices, no con­cern emer­ges regar­ding the subject’s men­tal functioning.

Through the man­da­tory school as well as the first two and a half years of high school, the sub­ject did slightly bet­ter than average. He did, how­e­ver, drop out of the high school before the final exam. As far as the experts know, in this con­nec­tion he was not referred to follow-up or investi­ga­tion by any authority.

The experts the­re­fore do not find evi­dence of any form of sure uneven devel­op­ment throug­hout the subject’s child­hood and ado­le­scence, and the­re­fore no evi­dence that the sub­ject meet the cri­te­ria for any beha­vioral or devel­op­men­tal dis­or­der accor­ding to the dia­gno­s­tic manual ICD-10.

The sub­ject has never expe­ri­en­ced depres­sive pha­ses with a dura­tion of two weeks or more. He appears through the experts’ investi­ga­tions wit­hout depres­sive ideas in form of guilt, shame or feeling of hope­lessness. He denies having expe­ri­en­cing sad­ness, joy­lessness, redu­ced ini­tia­tive or lack of initiative.

The sub­ject has never expe­ri­en­ced a lif­ted mood las­ting for more than a week. Throug­hout the experts’ investi­ga­tion, he exhi­bits no increased psycho­mo­to­ric acti­vity, or per­ce­i­ved lif­ted mood. The subject’s speech is cohe­rent and with nor­mal syn­tax. He has no mind or voice strain. He is affect stable. There is no evi­dence of lack of impulse con­trol, neit­her ver­bally nor physically.

There is thus no evi­dence of eit­her depressed or raised mood, neit­her at the time of investi­ga­tion nor ear­lier. Through the infor­ma­tion obtai­ned from per­sons who know the sub­ject, as well from the wit­ness exa­mi­na­tions, no evi­dence emer­ges of such sym­p­toms, neit­her cur­rent nor pre­vious. Thus the experts do not find evi­dence that the sub­ject meets the ICD-10 cri­te­ria for any affec­tive disorder.

In the period from 1998 to 2002, the sub­ject was self-employed and lived with fri­ends 2001in a shared housing. A nor­mal con­nec­tion with fri­ends and family is descri­bed. Rela­tion­ships with women of his own age are also men­tio­ned, though not of a very long dura­tion. Through con­ver­sa­tions with the sub­ject and with his mot­her, as well as when reviewing the wit­nes­ses exa­mi­na­tions, the experts find no sure evi­dence of psycho­pat­ho­logy in the sub­ject during this period.

Star­ting from 2002, the con­tact with his peers decrea­ses. The sub­ject lived alone in a rented apart­ment. No rela­tion­ships with women are men­tio­ned. The subject’s dif­fe­rent com­mit­ments to various busi­ness acti­vities are descri­bed by him­self as success­ful, with many emp­loy­ees and high ear­nings. These infor­ma­tions can­not, accor­ding to the subject’s own infor­ma­tion, be veri­fied, neit­her through his tax cer­ti­fi­cate nor the busi­ness register.

The experts find that the sub­ject in the period from 2002 to 2006 had an increas­ing tendency to iso­late him­self, and that he gra­dually lost his func­tio­nal abi­lity. The experts have no sure evi­dence that can say when the subject’s psycho­tic sym­p­toms star­ted, but it can­not be exclu­ded that the onset of sym­p­toms was alre­ady in this period.

Based on the over­all docu­men­ta­tion of the case, there is surely a change in the subject’s func­tion from 2006.Witness exa­mi­na­tions of his fri­ends describe that from this point, the sub­ject wit­hd­rew from social con­tact, was more quiet, moved home to his mot­her, and stop­ped wor­king. The experts con­si­der the phe­n­omena to be wit­hdra­wal, iso­la­tion and ina­bi­lity to meet the demands of pro­fes­sio­nal life.

The subject’s mot­her has descri­bed how he tur­ned the day, played a lot of video games, and from that time on was the mostly alone in his room. The sub­ject did not par­ti­ci­pate in clea­ning or caring for the apart­ment, the care of his own clot­hes, or cook­ing. His mot­her did all the gro­cery shop­ping. The subject’s mot­her says that he did not give in to pres­sure for con­tac­ting the emp­loy­ment and social security office NAV to get assi­stance, be it of a prac­ti­cal or an eco­no­mical cha­rac­ter. The sym­p­toms are assessed by the experts to be exten­sive loss of func­tion, both prac­ti­cally, socially, eco­no­mically and in terms of employability.

From 2010 the subject’s mot­her descri­bes a qua­li­ta­tive change in his beha­vior. She says that the sub­ject from this point was con­cerned with infec­tions and his own appea­rance, and he was uncom­for­tably intense, irri­table and angry. He was increas­ingly keen to talk about poli­tics and his­tory, and his mot­her felt under pres­sure from him. She says that she had a hard time under­stan­ding what he wan­ted to say. She descri­bes the sub­ject as com­pletely beyond, and he belie­ved all the crap he said. The phe­n­omena are con­side­red by the experts to be expres­sions of psycho­tic delusions.

The subject’s mot­her says that he no lon­ger seemed to know how much dis­tance he should keep to her, as he could switch between sit­ting too close to her on the couch, and not wan­ting to accept the food she served. The beha­vior is assessed by the experts to be regu­la­tory dif­fi­cul­ties as a result of para­noid delusions.

The sub­ject has up to the pre­sent never rece­i­ved treat­ment from a psychiatric spec­ia­list. A sur­vey through the medi­cal records from GP XXXXXXX XXXXXXX does not reveal infor­ma­tion about sym­p­toms related to severe, men­tal ill­ness. A note from April 2011 has been found, in which the GP says the sub­ject in a phone con­sul­ta­tion says he uses a face mask indoor. The phe­n­ome­non is con­side­red to be cau­sed by a para­noid delusion.

Throug­hout all the experts’ rese­arch, the sub­ject appea­red with clear con­scious­ness, and aware of time and place and situa­tion. The sub­ject used nume­ri­cal values ​​and per­cen­ta­ges to a grea­ter extent than is com­mon in regu­lar speech. He uses a tech­ni­cal, unemo­tio­nal and not very dyna­mic lan­guage in the conversation.

The sub­ject appea­red emo­tio­nally flatte­ned, with com­p­lete emo­tio­nal dis­tance to his own situa­tion and to the experts.

The sub­ject main­tains it was fair that the vic­tims were kil­led; he does not regret and feels no guilt. He belie­ves that the vic­tims died as a con­se­quence of his love for the Nor­we­gian people. When asked for an assess­ment of his own actions, his con­si­de­ra­tions remain wit­hout empathy. The sub­ject esti­ma­tes the con­se­quen­ces of the mur­ders for his own repu­ta­tion and future impact, and furt­her how the kil­lings could influ­ence and pos­sibly acce­le­rate the poli­ti­cal pro­ject of a future take­over of power in Europe. The sub­ject is unable to take the vic­tims’ or the community’s per­s­pec­tive in rela­tion to the cri­mi­nal acts.

The sub­ject does not express feelings for the per­sons clo­sest to him. He descri­bes all topics, from child­hood to the cri­mi­nal actions and their exe­cutions, with an ope­ra­tio­na­lized lan­guage wit­hout any emo­tio­nal com­po­nent. The sub­ject appears with a mar­ked emo­tio­nal flatte­ning and severe empathy failure.

The sub­ject has a light gla­ring look and blinks a lot. He appears with a slightly redu­ced facial expres­sion and a somewhat rigid body lan­guage, as he moves very little on the chair during the investi­ga­tions. The experts con­si­der this as light psycho­mo­to­ric retardation.

The sub­ject uses unusual terms, e.g. low-intensity civil war, mili­tary order, mili­tary tri­bu­nal, exe­cutio­ner, and ope­ra­tion. The ter­mi­no­logy used is entirely lin­ked to the subject’s notion that there is a civil war going on in the coun­try and is con­side­red as expres­sions of under­ly­ing, para­noid delusions.

The sub­ject uses unusual terms such as estab­lis­hed rights, sover­eign, power of defi­nition, respon­s­i­bi­lity, love of the (my) people, uni­que, pio­neer and new regent related to descrip­tions of his own position. The ter­mi­no­logy used is con­side­red as an expres­sion of under­ly­ing, gran­diose delusions.

The sub­ject pre­sents self-made words like natio­nal Dar­wi­nist, suici­dal Marx­ist and suici­dal huma­nism, Knight Chief Jus­tice, Chief Jus­tice Knight Com­man­der, Knight Chief Jus­tice Mas­ter and Knight Chief Jus­tice Grand Mas­ter. The terms are con­side­red to be neologisms.

The sub­ject belie­ves that he by estab­lis­hed right is the ideo­lo­gical lea­der of the orga­niza­tion Knights Temp­lar, which has a man­date to be a mili­tary order, mar­tyr orga­niza­tion, mili­tary judi­cial chair, judge, jury and exe­cutio­ner. He belie­ves he has the respon­s­i­bi­lity of deci­ding who shall live and die in Nor­way. The respon­s­i­bi­lity is per­ce­i­ved as real, but bur­dens­ome. The phe­n­omena con­side­red as a bizarre, gran­diose delusions.

He belie­ves that a sig­ni­fi­cant pro­portion of the popu­la­tion (seve­ral hundred thou­sand) sup­ports the cri­mi­nal actions. He belie­ves that his love is over-developed. He thinks he is a pio­neer in a Euro­pean civil war. He com­pa­res his situa­tion to his­to­ric war heroes such as Tsar Nicholas and Queen Isa­bella. The phe­n­omena are con­side­red gran­diose delusions.

The sub­ject belie­ves it is likely, alt­hough with somewhat vary­ing esti­ma­tes of the pro­ba­bi­lity in per­cent, that he can become the new regent in Nor­way after the coup and take­over of power. If he beco­mes the new regent, he will take the name of Sigurd II the crusa­der. He belie­ves he has given five mil­lion kro­ner to the struggle. He thinks he may one day be respon­s­ible for the depor­ta­tion of seve­ral hundred thou­sand Mus­lims to ports in North Africa. The phe­n­omena are con­side­red gran­diose delusions.

The sub­ject belie­ves that eth­nic cle­an­sing is going on in Nor­way, and he lives with the fear of being kil­led. He belie­ves that a nuclear third world war may be trigge­red as a result of the events he is a part of. He belie­ves there is a civil war going on in the coun­try. The sub­ject is wor­king on sug­ge­sted solu­tions that would improve our eth­nic Nor­we­gian gen­etic pool, era­di­cate dise­ase, and reduce the divorce rate. He envi­sions reser­ves (for “indi­genous Nor­we­gi­ans”), DNA tes­ting, and lots of birth facto­ries. The ideas con­side­red as part of a bizarre, para­noid delu­sio­nal system.

The sub­ject belie­ves that the Glücks­bur­gers (The Nor­we­gian and Euro­pean royal house, experts’ note) will be revo­lu­tio­na­rily rem­oved in 2020.As an alter­na­tive to the new regent being recruited from the Guar­dian Coun­cil, DNA tests will be con­ducted of the remains of St. Olav and Harald Hard­råde. Then the Nor­we­gian popu­la­tion will be DNA tested to find the one with the grea­test gen­etic simi­larity, who can then be appointed as the country’s new regent. These ideas are also assessed as part of a bizarre, para­noid delu­sio­nal system.

Audi­tory hal­lu­ci­na­tions and pos­sible influ­ence phe­n­omena can­not be con­fir­med, since the sub­ject main­tains that his forms of com­mu­ni­ca­tion with like-minded per­sons are secret. The experts sus­pect that audi­tory hal­lu­ci­na­tions and/or influ­ence phe­n­omena have been or are pre­sent, but have no evi­dence for this.

The sub­ject shifts between refer­ring to him­self as I and we, i.e. sin­gu­lar and plu­ral. The experts assess the sym­ptom to repre­sent a fuzzy iden­tity expe­ri­ence and depersonalization.

The sub­ject is some­ti­mes dif­fi­cult to follow, because he quickly switches topics and must be brought back by to it by ques­tions. He associa­tes a lot, and his associa­tions almost always take him, regard­less of the approach, back to his poli­ti­cal mes­sage, its per­ce­i­ved mis­sion and position. The phe­n­ome­non is con­side­red as a mode­rate associa­tion disorder.

When he is given the opport­u­nity to talk freely, the sub­ject inces­santly cir­c­les around the same the­mes. He repeats over and over again the same details rela­ting to his own knight­hood, radi­ca­liza­tion, orga­niza­tion, Knights Temp­lar, upcoming coup and take­over of power in Nor­way and Europe. The phe­n­ome­non is con­side­red by the experts as perse­ve­ra­tion. There is no lat­ency or thought block during the con­ver­sa­tion. The sub­ject does not exhi­bit dis­or­ga­nized behavior.

The sub­ject con­si­ders his own pri­vate and per­so­nal expe­ri­en­ces of param­ount impor­tance to social issues and deci­sions. For example, the sub­ject belie­ves that his use of smoke­less tobacco, nico­tine, and candy is war stra­tegy. Furt­her­more, he descri­bes pri­vate move­ments and acti­vities as guid­e­li­nes for future revo­lu­tio­nary knights in his compendium.

The subject’s cog­ni­tive func­tions are incon­spi­cuous as regards limi­ted intel­lec­tual capa­bi­lities. He is focu­sed in con­ver­sa­tion, he has unusu­ally good memory both of details and cir­cums­tan­ces, and his com­pen­dium testi­fies a great capa­bi­lity of detail and dea­ling with a large amount of issues. He has also mana­ged to plan and carry out a highly com­pli­cated act.

The subject’s abi­lity to reach an over­all cog­ni­tive under­stan­ding of him­self and his rela­tion­ship to the out­side world, is fai­ling. The sub­ject is not able to see him­self from anot­her per­s­pec­tive than his own. In par­ti­cu­lar, this is mani­fest in his ina­bi­lity to under­stand or empat­hize with the out­side world’s reac­tion to the cri­mi­nal acts. The sub­ject pre­sents his expecta­tions to the out­side world’s reac­tions in accor­dance with his own delu­sions. He descri­bes the explo­sion and kil­ling as bru­tal but bril­li­ant. His com­ments to the actions are pec­u­liar and somewhat bizarre, as he descri­bes him­self as a hero, knight, and with too much love.

The descri­bed, psycho­tic sym­p­toms appear to have come gra­dually. There is evi­dence of con­ti­nuous deteriora­tion from 2006, per­haps also with pro­dromi (“for” sym­p­toms, experts’ note.) much ear­lier. The time of first appea­rance coin­ci­des with a total fai­lure, both socially, prac­ti­cally and pro­fes­sio­nally. Since 2009, the sub­ject has descri­bed thoughts about eaves­drop­ping and surveil­lance. From 2010, it is descri­bed that the sub­ject, also through acqui­ring weapons and doing recon­nais­sance, has acted in accor­dance with his psycho­tic symptoms.

In his expla­na­tion given to police at 20.15 on 22 July 2011, the sub­ject says that he is the com­man­der and says furt­her: We are crusa­ders and natio­na­lists. The sub­ject says the cri­mi­nal acts on that day mani­fest the start of a very bloody civil war. In the same expla­na­tion, he main­tains that Knights Temp­lar Nor­way has given him aut­hority to exe­cute A, B and C trai­tors, and that the orga­niza­tion is the top mili­tary, police and poli­ti­cal aut­hority in Nor­way. The sym­p­toms are con­side­red to be gran­diose and para­noid delusions.

The dia­gno­s­tic manual ICD-10 lists as gene­ral require­ments for dia­gnos­ing schi­zoph­re­nia, that at least one very obvious, (or alter­na­tively two or more if the sym­p­toms are vague) sym­p­toms in the sym­ptom groups a) to d) must have been pre­sent for at least a month or more.

The experts find that the require­ment is met, as the sub­ject for a period of one month or more has had clear sym­p­toms in the following sym­ptom groups:

(b): Delu­sions regar­ding per­cep­tion and con­trol, as exemp­li­fied by the feeling that the sub­ject knows what others think.

(d): Per­sis­tent, bizarre delu­sions, exemp­li­fied by the idea that he is par­ti­ci­pa­ting in a civil war where he is respon­s­ible for deci­ding who shall live and die, and that he expects a power take­over in Europe.

The dia­gno­s­tic manual ICD-10 says that the dia­gno­sis can also be made if sym­p­toms from at least two of the sym­ptom groups e) to h) have been pre­sent for a sub­stan­tial part of a month or more. The experts also find that this alter­na­tive require­ment is met, as the sub­ject for a period of one month or more has had clear sym­p­toms from the following sym­ptom groups:

(f): Inter­rup­ted or sud­den thoughts, exemp­li­fied by occa­sio­nal perse­ve­ra­tion, associa­tive speech and neologisms.

(h):    Nega­tive sym­p­toms, as exemp­li­fied by the mar­ked emo­tio­nal flattening.

The experts add that sym­p­toms from ICD-10 sym­ptom group i) also have been pre­sent for a period of more than six months;

(i):     A sig­ni­fi­cant and sustai­ned qua­li­ta­tive change in some aspects of per­so­nal beha­vior, descri­bed by a mar­ked decline in social func­tioning, prac­ti­cal and eco­no­mic collapse.

After the gene­ral require­ments for schi­zoph­re­nia are found to be satis­fied, the con­dition is clas­si­fied accor­ding to the dia­gno­s­tic manual ICD-10 sub­groups, depen­ding on the wor­king out of the sym­ptom profile.

The sub­ject exhi­bits a pic­ture of stable, detai­led and com­pre­hen­sive, para­noid and gran­diose delu­sions. The sym­p­toms have a bizarre cha­rac­ter. The sub­ject exhi­bits no pro­mi­nent inter­fe­rence in his will, his speech is not dis­tur­bed, and he has no cata­to­nic symptoms.

Thus, the experts find that the sub­ject satis­fies the cri­te­ria for the ICD-10 dia­gno­sis F 20.0 Para­noid schi­zoph­re­nia. The experts refer to the investi­ga­tion of the sub­ject by psycho­met­ric tests in Chap­ter 6. The investi­ga­tions referred to con­firm the diagnosis.

During the con­ver­sa­tions, the sub­ject appears with com­pre­hen­sive ideas of kil­ling named indi­vi­duals, such as the Royal Family, the Prime Minis­ter and For­eign Minis­ter. His list of Nor­we­gi­ans who must die if they do not change the poli­ti­cal course encom­pas­ses hund­reds of thou­sands, inclu­ding jour­na­lists, party poli­ti­ci­ans, pro­mi­nent social com­men­ta­tors and intel­lec­tuals, as well as the experts. The ideas are con­side­red as exten­sive, homici­dal thoughts.

The sub­ject denies spec­i­fic suici­dal thoughts or plans. How­e­ver, he says that his own death by mar­tyr­dom is desi­rable and an ideal. He has con­side­red self-terminating, which he thinks is related to a capi­tu­la­tion during com­bat ope­ra­tions. The experts find that both the subject’s term mar­tyr­dom and his con­cept of self-termination must be under­stood as suicide. The sub­ject has had spec­i­fic ideas and plans for this, and does not exclude that it may be neces­sary at a later date, for example, after the trial.

The experts find that there is a con­si­de­rable risk that the sub­ject may attempt to end his life through an act directed against him and/or the ones he threa­tens on their lives. The sub­ject thus appears both as suici­dal and as a real dan­ger to others.

The experts have con­side­red whether the subject’s sym­p­toms may be con­sis­tent with the dia­gno­s­tic manual ICD-10’s cri­te­ria for the dia­gno­sis F 22.0 Para­noid psycho­sis. Accor­ding to ICD-10, this is a con­dition cha­rac­te­rized by eit­her one single or seve­ral related delu­sions. The cri­te­rion is not met, as the subject’s bizarre delu­sions cover his entire life and thought.

Clear emo­tio­nal flatte­ning, alte­red speech and beha­vior change are, accor­ding to the ICD-10, not com­pa­tible with the dia­gno­sis. The sub­ject has a mar­ked affec­tive flatte­ning, alte­red speech in the form of associa­tion dis­tur­bance and perse­ve­ra­tion, and his beha­vior is motive by his psycho­tic sym­p­toms. Thus, the experts find that the ICD-10 cri­te­ria for this dia­gno­sis are not met.

The experts discus­sed the pos­si­bi­lity that the sub­ject meet the cri­te­ria for various per­so­na­lity dis­or­ders. For such dia­gno­s­tics to be meaning­ful, the subject’s basic ill­ness, para­noid schi­zoph­re­nia, must be well treated first. Only in a phase where he, stably and over time, does not have any psycho­tic sym­p­toms, it will be pos­sible to eva­luate whether the subject’s lack of empathy and his over­all cog­ni­tive fai­lure are also rooted in qua­lities related to his per­so­nal characteristics.

From the case docu­ments and the experts’ investi­ga­tions, no evi­dence has been dis­covered that the sub­ject has abu­sed alco­hol. He con­firms having taken mari­juana on two occa­sions, the last intake seve­ral mon­ths before the cur­rent actions. The intake does not qua­lify for any sub­stance abuse dia­gno­sis. Apart from this, he has not used ille­gal drugs.

The sub­ject con­firms that he in a total of three periods has used ana­bo­lic ste­roids. The first period las­ted from February to May 2010.The second period las­ted from Decem­ber 2010 to February 2011. He used the drug mar­ke­ted as Win­st­rol.

The third period las­ted from 27 April to 15June 2011, when the sub­ject used the drug mar­ke­ted as Dianabol. This period went directly over in a period that las­ted until the cri­mi­nal actions, when the sub­ject says to have taken Win­st­rol.

The sub­ject has furt­her stated that he used the resto­ra­tive drug ECA stack (Ephed­rine, caf­feine and aspi­rin, experts’ note) prior to the action time. He said that he used three caps­u­les during the week before the cri­mi­nal actions. The last intake is said to have been at 14:30 hours on 22 July 2011.

He does not describe sym­p­toms of addic­tion or expe­ri­en­ced men­tal change as a result of the use. Neit­her does he describe acute intox­i­ca­tion sym­p­toms related to the use of ste­roids or the com­bi­na­tion of ephed­rine, caf­feine and aspirin.

In the periods he used ana­bo­lic ste­roids and/or ECA stack, the sub­ject has had psycho­tic sym­p­toms. The experts find no evi­dence that the ste­roids or the com­bi­na­tion of ephed­rine, caf­feine and aspi­rin have cau­sed the sym­p­toms, that were descri­bed as cer­tainly pre­sent before the first cycle of ste­roids star­ted in 2010, and also pre­sent regard­less of con­sump­tion of ECA stack.

The experts thus find no evi­dence that the use of ste­roids or the com­bi­na­tion of ephed­rine, caf­feine and aspi­rin jus­ti­fies any dia­gno­sis in the ICD-10 chap­ter Men­tal and beha­vioral dis­or­ders due to psychoa­c­tive sub­stan­ces, F 10 - F 19, before, after or during the acts on 22 July 2011

The experts find that the sub­ject had taken ste­roids, ephed­rine, caf­feine and aspi­rin on 22 July 2011. The use was not based on medi­cal needs, and is thus con­side­red medi­cally unfoun­ded. The sub­ject thus meets the cri­te­ria for the ICD-10 dia­gno­sis F-55abuse of addic­tive sub­stan­ces on the time of action on 22 July 2011.

After he was reman­ded in custody, the sub­ject has not taken drugs, ste­roids or any com­bi­na­tion of ephed­rine, caf­feine and aspi­rin. Thus, he does not meet any of the dia­gno­sis cri­te­ria at the time of investigation.

Over­all, the experts find that the sub­ject at the time of action met the ICD-10 cri­te­ria for the dia­gno­ses F 20.0 Para­noid schi­zoph­re­nia and F 55 abuse of non-addictive sub­stan­ces (ste­roids, caf­feine, ephed­rine and aspirin.)

At the time of the sur­vey, the sub­ject met the cri­te­ria for the ICD-10 dia­gno­sis F 20.0 Para­noid schizophrenia.

8.3 DETAILED RESPONSE TO THE MANDATE

Regar­ding the for­en­sic psychiatric term “psycho­tic”, cf. Penal Code § 44, first para­graph, the experts state the following:

Gene­ral comment:

A psycho­sis will involve a serious depar­ture from rea­lity in terms of per­cep­tual dis­tur­ban­ces, thought dis­or­ders, or clear delusions.

  • ·     A sense illu­sion will con­sist of audi­tory, visual, odor, taste, or tactile hal­lu­ci­na­tions. Hal­lu­ci­na­tions have the same clarity and clarity as nor­mal visual or audi­tory sen­sa­tions, but wit­hout the exist­ence of any real exter­nal cause of the experience.
  • ·      Thought dis­or­ders are chan­ges in form of thought (not the content)

Examp­les include inter­rup­tions of thought, new for­ma­tions of con­cepts, or lack of cohe­rence in thought or speech.

  • ·     A delu­sion is a change in thought con­tent (not form), having a false sense of somet­hing, a strange idea, like feeling perse­cuted and sys­te­ma­ti­cally moni­to­red or influ­en­ced, wit­hout being based on rea­son or obser­va­tion, and being dif­fi­cult to cor­rect. Delu­sions (s) may be single, iso­la­ted, frag­men­ted, or more exten­sive and com­plex, even all-encompassing.
  • ·     Deper­so­na­liza­tion is a change in the expe­ri­ence of one­self. The per­son in ques­tion may feel that he/she is an alien, chan­ges iden­tity, is unreal or that he/she sees him/herself at a distance.
  • ·     Derea­liza­tion is when some­one expe­ri­en­ces the world as dif­fe­rent, as changed, or as unreal.

Spec­i­fic comment:

We refer to the dia­gno­s­tic assess­ment above, where the sub­ject at the time of action on 22 July 2011 is found to fill the cri­te­ria for ICD-10 dia­gno­sis F 20.0 para­noid schi­zoph­re­nia. The subject’s serious men­tal ill­ness was at this time untreated. He has not, neit­her before nor after the cri­mi­nal acts, rece­i­ved adequate treat­ment for his disease.

The experts have con­ducted exten­sive investi­ga­tions of the sub­ject, and the con­ver­sa­tions and the psycho­tic sym­p­toms that emer­ged through these investi­ga­tions are ela­bo­rated in the statement’s Chap­ter 5, Back­ground and expla­na­tion by the indi­vi­dual under observation.

The subject’s sym­p­toms and dia­gno­sed dis­or­der are wit­hin the sym­ptom and dia­gno­s­tic cir­cuit that meets the cri­te­ria of the legal con­cept of psycho­sis as inten­ded by the Penal Code § 44 rela­ting to men­tal incapacity.

Since at least 2006, the sub­ject has had a clear dise­ase pro­gres­sion with both posi­tive sym­p­toms (delu­sions, thought dis­or­der, deper­so­na­liza­tion, and derea­liza­tion), and nega­tive sym­p­toms (total empathy fai­lure, severe affec­tive flatte­ning and an ina­dequate expres­sion of affect).He also lacks com­plex and over­all cog­ni­tive func­tions, as pointed out by the experts above.

The subject’s loss of func­tion pos­sibly began as early as 15-16 years of age with tag­ging, police reports, and then drop-out before finish­ing high school. The experts have no sure evi­dence of dise­ase pro­gres­sion, i.e. con­sis­ting of active sym­p­toms, in the period 1998 to 2006. The subject’s func­tion does, how­e­ver, appear to have been gra­dually weake­ned during the period, as he gra­dually wit­hd­rew from social con­tact, and even­tually drop­ped com­pletely out of the pro­fes­sio­nal life.

After the subject’s return home to his mot­her in 2006, his func­tio­nal impair­ment became com­p­lete, with a total fai­lure of a prac­ti­cal, eco­no­mic, social and pro­fes­sio­nal nature. At the same time a pro­gres­sive devel­op­ment of sym­p­toms is descri­bed, with a gra­dually devel­o­ped sys­tem of bizarre para­noid and gran­diose delu­sions, where the sub­ject belie­ves he is a par­ti­ci­pant in an ongo­ing civil war, and that he after a coup and take­over of power will par­ti­ci­pate in the design of a new Europe.

The sub­ject starts to act in accor­dance with his delu­sions at the begin­ning of 2010, with purcha­ses and plan­ning of armed action. Over the last eigh­teen mon­ths before the cri­mi­nal actions, he has dedi­cated all his time and atten­tion to his delu­sio­nal uni­verse, and his mot­her con­firms exten­sive sym­p­toms, con­spi­cuous beha­vior and lack of com­mu­ni­ca­tion skills right up to the cur­rent events.

The sub­ject ack­now­led­ges having car­ried out the cri­mi­nal actions. The actions are con­side­red to be in direct cor­re­la­tion with the delu­sio­nal world in which he per­ce­i­ves to be in a civil war, with the threat of extinc­tion of his race, as well as fear of vio­lence and the geno­cide of what he descri­bes as my people. He claims to have the respon­s­i­bi­lity to decide who shall live and die in the coun­try. His extremely egocent­ric uni­verse with almost all-encompassing ideas of great­ness cha­rac­te­rizes all his assess­ments and his whole appea­rance, regard­less of con­text, and then beco­mes the dri­ving force behind his actions on 22 July 2011.

There is no evi­dence of abrupt or inter­mit­tent chan­ges in the subject’s psycho­tic sym­p­toms during the period before the cur­rent events. Thus, there is no evi­dence that the mani­fes­ta­tion of the subject’s sym­p­toms was changed as a result of taking ste­roids or the invi­gora­ting drug ECA stack prior to the cri­mi­nal acts.

Based on the descrip­tions, the experts find that the mani­fes­ta­tion of his sym­p­toms remains unchanged from before the cri­mi­nal actions and throug­hout the whole investigation.

The con­clu­sion is thus that the sub­ject is belie­ved to have been psycho­tic at the time of the cri­mi­nal actions and that he was psycho­tic during the observation.

Regar­ding the for­en­sic psychiatric terms “uncon­scious”, cf. Penal Code § 44 first para­graph, and “acted under a strong dis­tur­bance of con­scious­ness that was not a result of self-intoxication”, cf. Penal Code § 56 c, the experts state the following:

Gene­ral comment:

With loss of con­scious­ness is inten­ded that a per­son for orga­nic or psycho­lo­gical rea­sons is unable to absorb or process sen­sory input (per­form cog­ni­tive func­tions), and the­re­fore has not been able to recall what has happened.

This is in con­trast to a psycho­lo­gical repres­sion, where an epi­sode is imprinted and sto­red in memory, but dif­fi­cult to recall because it is per­ce­i­ved as threate­ning, embar­ras­sing or unwanted.

Examp­les of orga­nic cau­ses are con­cus­sion, brain damage after being expo­sed to sol­vents, and intox­i­ca­tion. A psycho­ge­nic fai­lure of imprin­ting can hap­pen e.g. after extremely shock­ing emo­tio­nal experiences.

Spec­i­fic comment:

The sub­ject reports no epi­lep­tic seizu­res, black­outs, head injury with loss of con­scious­ness, severe sleep dis­or­ders, sleep depri­va­tion or sleepwalking.

Both during exten­sive inter­ro­ga­tions and many long con­ver­sa­tions with the experts, the sub­ject has descri­bed his actions on 22 July 2011 to the smal­lest detail. Also during the recon­struc­tion of events at Utøya, he has given a detai­led expla­na­tion that does not omit any period of time. He indi­ca­tes, how­e­ver, some memory loss regar­ding the most detai­led descrip­tions there, and he belie­ves that he does not remem­ber because at that time, he was under tremen­dous pres­sure and stress. He is, how­e­ver, able to make a cohe­rent account of his move­ments and partly of his thoughts, also from this part of the lapse of time.

The experts have no rea­son to believe that his intake of ste­roids and ECA stack had any effect other than sti­mu­la­ting him­self to over­come phy­si­cal bar­riers with heavy equip­ment, as well as small men­tal bar­riers, wit­hout the intake having affected his rea­lity ori­en­ta­tion sig­ni­fi­cantly. Thus, the infor­ma­tion that the sub­ject has pro­vi­ded from the period of action is detai­led, and he descri­bes having car­ried out com­plex proces­ses imme­dia­tely prior to, during and imme­dia­tely after the cri­mi­nal actions.

Uncon­scious­ness assu­mes com­p­lete memory loss during the rele­vant period, and the­re­fore can­not be said to have been pre­sent. In this con­nec­tion, one refers to NOU 1990:5 and cir­cu­lars from the Att­or­ney Gene­ral on 3 Decem­ber 2001.

In an expert state­ment dated 7 Novem­ber 2011, pro­fes­sor of for­en­sic tox­i­co­logy at the NIPH, Jørg Mor­land, wri­tes the following in the sec­tion Ana­ly­sis results:

In his chap­ter Drug Effects in the period from 1200 to 1530 on 22 July 2011, expert Mor­land writes:

(…) Accor­ding to the expert’s assess­ment, the impact in the period 1200 to 1530 may be descri­bed as a slight to mode­rate influ­ence of a cen­tral ner­vous sti­mu­lant, depen­ding on the con­cen­tra­tion. The impact is dif­fi­cult to com­pare with the influ­ence of alco­hol, due to fun­da­men­tal dif­fe­ren­ces in the effect mecha­nism between ephed­rine and alco­hol, but accor­ding to the expert’s assess­ment, the impact can pro­bably be equa­ted to the impact that may be achie­ved by an intake of amp­he­ta­mine (by mouth) of doses of the order of 10-30 mg of amp­he­ta­mine by non-habitual users. The expert assu­mes a cer­tain rein­for­ce­ment of the ephed­rine effects because of the sig­ni­fi­cant effects of caf­feine con­cen­tra­tions that may have existed.

In his chap­ter Pos­si­bi­lity of additio­nal exposure as a result of regu­lar use of ephed­rine and ste­roids in the period prior to 22 July 2011, expert Mor­land wri­tes the following: The reported use of ephed­rine does not repre­sent a long-term high-dose intake. Neit­her do the ana­ly­ti­cal results point toward high dosage con­sump­tion. The­re­fore, the pos­si­bi­lities of a psycho­sis of some dura­tion trigge­red by ephed­rine must be con­side­red as minimal.

Accor­ding to the expert’s assess­ment, the stated use of ana­bo­lic ste­roids is unlikely to have cau­sed additio­nal influ­en­ces, but the pos­si­bi­lity of enhan­ced aggres­sion and hypomania/mania can­not be com­pletely excluded.

Strong dis­tur­bance of con­scious­ness is a legal term that does not have any clear medi­cal inter­pre­ta­tion. The Penal Code Coun­cil descri­bed the con­cept of strong dis­tur­bance of con­scious­ness in NOU 1974:17, page 57, as a con­dition where an individual’s per­cep­tion, ori­en­ta­tion, per­cep­tion and judgment are greatly impai­red or severely dis­rup­ted. Based on the pre­sent expert descrip­tions, the expert assess­ment by pro­fes­sor Mor­land and the above con­si­de­ra­tions, it is assu­med, with the reser­va­tion that the court may assess the infor­ma­tion dif­fe­rently, that such a state has not been pre­sent. There is no evi­dence that the con­cept of strong dis­tur­bance of con­scious­ness would be applicable.

The experts the­re­fore con­clude that the sub­ject is not belie­ved to have been uncon­scious or having acted under a strong dis­tur­bance of con­scious­ness at the time of the cri­mi­nal acts.

Regar­ding the for­en­sic psychiatric terms “men­tally retar­ded to a high degree” cf. Penal Code § 44, second para­graph, and “men­tally retar­ded”, cf. Penal Code § 56 c, the experts state the following:

In early child­hood, the sub­ject was observed by the child and ado­le­scent psychia­try. The rea­son for this was said to be a somewhat active boy who exhaus­ted his mot­her, an inte­rac­tion pro­blem between the mot­her and son was also descri­bed. After obser­va­tion, one con­clu­ded by recom­men­ding fos­ter care for the sub­ject, in order to avoid the devel­op­ment of a more severe psycho­pat­ho­logy. Not­hing was stated after obser­va­tion regar­ding any devel­op­men­tal dis­or­der, nor any­thing about redu­ced abi­lities of any kind.

During the inter­views with the experts and police inter­ro­ga­tion, the sub­ject appears with intel­lec­tual resources above average. During pri­mary and lower secondary school, his per­for­mance was slightly above average, as was the case in upper secondary school, until he drop­ped out in the middle of third grade. After this, the sub­ject had some rela­tively incon­spi­cuous years in the nor­mal job mar­ket. The experts find no rea­son to sus­pect any capacity reduc­tion of any kind or degree.

The experts con­clude that the sub­ject is not belie­ved to be men­tally retar­ded, neit­her in a high nor in a low degree.

Regar­ding the for­en­sic psychiatric con­cept of “serious men­tal dis­or­der with a sig­ni­fi­cantly redu­ced abi­lity of rea­li­s­tic assess­ment of one’s rela­tion­ship with the out­side world, though not psycho­tic”, cf. Penal Code § 56 c, the experts state the following:

Posi­tive con­clu­sion of the for­en­sic psychiatric term psycho­sis, cf. Penal Code § 44, and posi­tive con­clu­sion of the for­en­sic psychiatric term serious men­tal dis­or­der with a sig­ni­fi­cantly impai­red abi­lity of rea­li­s­tic assess­ment of one’s rela­tion­ship with the out­side world, though not psycho­tic, cf. Penal Code § 56 c are mutually exclu­sive. Due to the posi­tive con­clu­sion of man­date item 1 above, this item is not answered.

If the court were not to uphold the experts’ con­clu­sion regar­ding item 1 of the man­date, cf. Penal Code § 44, the experts may pro­duce a sup­ple­men­tary state­ment on this point.

As a con­se­quence of the posi­tive con­clu­sion of the mandate’s item 1, one turns to the answer of the following item:

In addition if par­ti­cu­lar sanc­tions in the case of men­tal insa­nity are applicable

7. If the experts believe that the sub­ject was in a con­dition descri­bed by the Penal Code § 44, or they are in any doubt about this, they are asked to investi­gate the pro­gno­sis for the disease/condition. The experts are asked to con­si­der what treat­ment and what other measu­res are nee­ded to obtain an opti­mal pro­gno­sis, what improve­ment may then be achie­ved, and the time frame for this. The sup­port that the sub­ject is get­ting from the health care sys­tem shall be par­ti­cu­larly examined.

The experts are also reque­sted to exa­mine the pro­gno­sis in case the sub­ject does not rece­ive such treat­ment, inclu­ding the risk of future vio­lent actions.

Pro­gno­sis for the condition

The experts have found that the sub­ject meets the dia­gno­s­tic manual ICD-10 cri­te­ria for the dia­gno­sis F 20.0 Para­noid schi­zoph­re­nia. He has had sym­p­toms of the dis­or­der at least since 2006, with gra­dual wor­sening. He has at no time sought or rece­i­ved psychiatric treat­ment for his disorder.

Schi­zoph­re­nia is a life­long men­tal dis­or­der with an over­all life­time pre­va­lence of around 1%.The sym­p­toms usu­ally arise in early adult­hood. Dia­gno­sis is based on the patient’s own report of expe­ri­en­ces, as well as observed beha­vior. There are cur­rently no labo­ra­tory tests that prove schi­zoph­re­nia. Neit­her is there any cura­tive treat­ment for the disorder.

Rese­arch has not been able to iso­late a single orga­nic cause of schi­zoph­re­nia, but one knows that gen­etics plays a sig­ni­fi­cant role in the devel­op­ment of the dise­ase. Neu­ro­bio­logy, sub­stance abuse and psycho­lo­gical and social proces­ses also seem to play a role.

As a result of the numerous pos­sible com­bi­na­tions of sym­p­toms, it is dis­puted whether the dia­gno­sis descri­bes a single dis­or­der, or whether we are tal­king about mul­tiple, sepa­rate syndromes.

An unusu­ally high dopa­mine acti­vity in the meso­lim­bic areas of the brain has been found in people with schi­zoph­re­nia. The cor­ner­stone in treat­ment of schi­zoph­re­nia is antip­sycho­tic medi­ca­tion. This type of medi­ca­tion pri­ma­rily works by suppres­sing dopa­mine acti­vity in the brain.

In severe cases, where pati­ents can be a dan­ger to them­sel­ves and/or others, hos­pi­ta­liza­tion may be nee­ded for shor­ter or lon­ger periods.

The dis­or­der is belie­ved to pri­ma­rily affect cog­ni­tive abi­lities, but it also con­tri­bu­tes gene­rally to chro­nic pro­blems with beha­vior and feelings. Average life expectancy for people with schi­zoph­re­nia is 10 to 12 years lower than for people wit­hout the dis­or­der, due to mul­tiple phy­si­cal health pro­blems and a hig­her suicide rate (about 5%).

Accor­ding to sur­vey artic­les, there are three forms of treat­ment that show a sig­ni­fi­cant effect when trea­ting para­noid schi­zoph­re­nia. These are psycho­e­du­ca­tion, assertive com­mu­nity treat­ment (ACT) 2 and treat­ment with antip­sycho­tic medi­ca­tion 3.These forms of treat­ment are over­lap­ping and must be con­side­red toget­her, since psycho­e­du­ca­tion is part of the ACT, and one of the pri­mary pur­po­ses of ACT is to main­tain the drug treatment.

The psycho­e­du­ca­tion aims at increas­ing the patient’s know­ledge and under­stan­ding of his or her own ill­ness. The trai­ning must be struc­tu­red and sys­te­ma­tic, and one of its pur­po­ses is to teach the pati­ent to rec­og­nize war­ning signs and even have a reper­toire of appro­priate coping stra­te­gies ready upon increased sym­ptom pressure.

The main prin­ciple of the ACT orga­niza­tion is multi-disciplinary team work by psychia­trists, psycho­lo­gists, social wor­kers, nur­ses and reha­bi­li­ta­tion staff. These teams pro­vide ser­vices in hos­pi­tals, at home, at school or work or where the pati­ent is located and is avai­lable around the clock. They also main­tain con­tact with pati­ents who do not coope­rate. Teams are espec­ially focu­sed on the pres­cri­bed medi­ca­tion being taken. The the­ra­peu­tic approach is psychoeducational.

Con­ti­nuous drug the­rapy is the single most impor­tant pro­gno­s­tic factor in the treat­ment of para­noid schi­zoph­re­nia. Sur­vey artic­les 4 show that inter­rup­tion of treat­ment or non-optimal intake of antip­sycho­tic medi­ca­tion repre­sents a for­mi­dably ele­vated risk of relapse, both in the short and lon­ger term.

Phar­ma­co­lo­gical treat­ment of para­noid schi­zoph­re­nia is not a sta­tic, but a con­ti­nuous and dyna­mic chal­lenge. For example, weight loss, weight gain, fever, or inci­dence of other bodily dise­ase may neces­si­tate rapid chan­ges in the dose or choice of medication.

Simi­larly, side effects or poor treat­ment response may require drug adjust­ments. It may also be neces­sary to decide com­pulsory drug treat­ment if it turns out that the sub­ject is unable to follow up medi­ca­tion on a volun­tary basis.

Since the sub­ject has not rece­i­ved treat­ment of the dise­ase, the experts have no basis for assess­ing how he can be expec­ted to respond to treat­ment. Gene­rally speak­ing, it is belie­ved that his sym­ptom pro­file will be dif­fi­cult to treat adequa­tely. This is because fas­ter and bet­ter effect on per­cep­tion dis­or­ders and severe thought dis­or­ders are observed more often com­pared to exten­sive delu­sions that have per­sis­ted for a long time. Only the furt­her cli­ni­cal devel­op­ment may pro­vide accu­rate know­ledge about this.

By far the most impor­tant chal­lenge in terms of the subject’s medi­ca­tion will be to catch up if he is care­less or com­pletely refu­ses to take antip­sycho­tic medi­ca­tion. With refe­rence to Nancy Andre­as­sen 5, this can be done in an opti­mal man­ner by regu­lar ​​use of tools that can quickly pick up even minor chan­ges in the subject’s sym­ptom pic­ture. Con­si­de­ring the shape his sym­p­toms have taken, such moni­to­ring would be done e.g. by the use of PANSS, posi­tive and nega­tive subscale.

The experts have also been asked to assess the risk of future vio­lence in case the sub­ject does not get such treatment/follow-up.

The experts have con­side­red whether struc­tu­red risk assess­ment instru­ments, such as the HCR 20, might help to investi­gate the risk of future vio­lence by the sub­ject. The pre­mise basis for such a sco­ring is broad, and the experts con­si­der that such a score would under­es­ti­mate the actual risk of future vio­lence by the sub­ject, because this dan­ger seems to be entirely related to his active psycho­tic symptoms.

It is taken into con­si­de­ra­tion that the sub­ject has car­ried out the cri­mi­nal actions, and thus kil­led 77 people with a desire to kill seve­ral hundred. The rea­son for the kil­lings is his para­noid psycho­tic delu­sions that he is par­ti­ci­pa­ting in a civil war, where he is respon­s­ible for deter­mi­ning who shall live and die. His mis­sion is to save the cul­ture and the genes of the Western world. He belie­ves that he, through these mur­ders, shows his knight­hood and bound­less love, and thus has an estab­lis­hed right to future positions of power in Europe and Nor­way. The kil­lings were planned.

The sub­ject has shown his abi­lity to long-term plan­ning and imple­men­ta­tion of his mur­derous intent. In con­ver­sa­tion with the experts, he has main­tai­ned that a num­ber of per­sons will be kil­led also in the future. The num­ber has varied from a few thou­sand to seve­ral hundred thou­sand, and the sub­ject men­tions dif­fe­rent sce­na­rios that may result in murder.

The sub­ject says that the kil­lings would have to take place as reta­lia­tion of actions the above-mentioned per­sons have alre­ady car­ried out. The subject’s homici­dal thoughts are related to offi­cial per­sons like the prime minis­ter and mem­bers of the royal family, but also people with no offi­cial sta­tus, like uni­ver­sity emp­loy­ees, emp­loy­ees of the various media com­pa­nies, emp­loy­ees at the nuclear reac­tor in Hal­den and poli­ti­cal demonstrators.

The sub­ject also inclu­ded the experts in his homici­dal thoughts. These thoughts appea­red after the sub­ject having had discus­sions with the experts for some time. The experts see is as appro­priate to men­tion this, because it shows that the subject’s homici­dal thoughts are obviously dyna­mic and influ­en­ced by the con­text in which the sub­ject finds him­self at any time.

The experts assume that a simi­lar sce­na­rio might unfold in the future, and believe there is a sig­ni­fi­cant risk that people in the subject’s prox­i­mity, like pri­son or hos­pi­tal emp­loy­ees, may also become part of his para­noid delu­sio­nal world and inclu­ded in his homici­dal thoughts.

Con­ti­nuous, antip­sycho­tic medi­ca­tion with adequate dosage, moni­to­ring of his con­dition by qua­li­fied staff, and even­tually trai­ning in rec­og­ni­zing his own sym­p­toms will be nee­ded to achieve sym­ptom con­trol. Moni­to­ring is also rele­vant for measu­ring blood con­cen­tra­tions after antip­sycho­tic treat­ment. Fai­lure to con­trol sym­p­toms may be due to the sub­ject not rece­i­ving treat­ment, or a result of a lack of effect of the assu­med adequate treatment.

For rea­sons men­tio­ned above, the experts find that a pos­sible out­come is that the treat­ment response may be small or absent. The sub­ject has no insight in his ill­ness. Thus, there is rea­son to expect pro­blems with achie­ving a the­ra­peu­tic alli­ance and volun­tary intake of antip­sycho­tic medication.

If one does not succeed in achie­ving sym­ptom con­trol, the experts con­si­der that the risk of future vio­lence by the sub­ject is very high.

The experts’ assess­ments in accor­dance with the man­date are deemed jus­ti­fied by the above.

Reser­va­tions are made regar­ding the court’s assess­ment of the avai­lable information.

All of the above assess­ments are based on a cli­ni­cal judgment invol­ving uncertainties.

9. CONCLUSION

After having con­ducted a for­en­sic psychiatric exa­mi­na­tion of Behring Anders Brei­vik, born 13/02/79, the experts find the following:

I. Regar­ding men­tal insa­nity (§ 44)

1. The sub­ject was psycho­tic at the time of the cri­mi­nal actions

2. The sub­ject was psycho­tic during observation

3. The sub­ject was not uncon­scious at the time of the cri­mi­nal actions

4. The sub­ject is not men­tally retar­ded to a high degree

II. REGARDING PENAL CODE § 56 C

1. The sub­ject did not act under strong dis­tur­bance of consciousness

2. The sub­ject is not men­tally retar­ded to a light degree.

 

Oslo, 29 Novem­ber 2011

Tor­geir Husby, Depart­ment chief phy­si­cian and spec­ia­list in psychiatry

Synne Sør­heim, spec­ia­list in psychiatry

 




Om du ikke følger Document på sosiale media kan du følge oss på e-post.

Donere engangsbeløp?Kan du forplikte deg til fast betaling?

Penger kan også doneres til kontonummer 15030249981. Du kan også støtte oss ved å kjøpe bøker eller varer.