Forensic psychiatric statement — Anders Behring Breivik (X)

Christian Skaug

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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

 





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