"If sanity and insanity exist, how shall we know them?"

A confluence of events, legal cases, pending legal decisions, journal articles and provocative radio programs this summer naturally lead us here at MT to ask: What is insanity?  What is evil?

The June 30 issue of The Lancet has a piece about the Norwegian Anders Breivik who killed 79 people last summer, asking if he is sane or insane, in fact the only question now before the court as it decides his sentence, as Breivik readily and proudly has claimed credit for the murderous rampage in Norway that shook the world last July.  And he claims as well that he is utterly sane, just a political activist with a point to make.  He was evaluated twice; one psychiatric evaluation found him sane and the other found him insane, diagnosing paranoid schizophrenia with persistent delusions (the questionable existence of the political organization which he claims to be a member of being a case in point).

The fact that psychiatrists do not agree on whether this man is insane, given that they are all dealing with the same man, the same actions and agreement as to who is responsible for them, and the same evidence, is an illustration of the difficulty in defining mental state.  

Both the methods and conclusions of the initial psychiatric report have been widely debated, including by several psychiatrists, after being leaked to the press. Critics said that Breivik's strange word usage, viewed in the first report as neologisms (made-up words or phrases that only have meaning to the speaker and often occur in the speech of people with schizophrenia), were not placed into a relevant right-wing political context. In January, the court decided that Breivik should be involuntarily observed in prison.

Health personnel affiliated with the prison testified in court and reported that they had not seen any signs of psychosis. Neither did the new forensic psychiatrists, Agnar Aspaas and Terje Tørrissen, who concluded that Breivik had dissocial and narcissistic personality disorders with paranoid traits. They believe that the excessive violence on July 22 was the result of extreme political attitudes, and not delusions. Husby and Sørheim think that right-wing extremism is not the defendant's primary issue, but a repository for his delusions. They found that Breivik displayed mental stimulation chiefly when talking about killing and violence.

The outcome of this debate for Breivik will determine whether he is sentenced to prison or to a mental institution for the rest of his life.  For the rest of us, that there can be a debate at all says a lot about the limits of social science, the cultural vs biological determinants of extreme (and not so extreme) behaviors, and how we know the difference, and much more about the sciences that dissect and describe human behaviors and societies.

And of course we've had our own legal drama here at Penn State, the case of Jerry Sandusky and the serial sexual abuse of children.  Is a pedophile insane?  If so, and if it's true that up to a quarter of all boys and a fifth of all girls are sexually abused, and if pedophilia is a form of mental illness, this suggests that a good fraction of the population is mentally ill. 

The constantly evolving DSM, the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric diagnosis, is another case in point.  The fact that it can evolve, that there can be disagreement about diagnoses, and that they can be a moving target speaks volumes about how much psychiatric research can in fact reveal in any objective way.  Indeed, its definitions and inclusions are decided by committees of 'experts' who would not necessarily agree, and while determining whether someone has diabetes or cancer in 1880 or 2012 perhaps hasn't changed that much, by comparison, behavior can be clinically normal sometimes and pathological at others.

Interestingly, these are categories -- affected or not -- and yet we know that behavior is certainly not categorical.  We all probably do some things at some times that some other person might think is too-too-odd to be normal.  And how many people do you have to kill, say, to have crossed from punishably normal to helplessly ill? What kind of science lies behind such treatments of behavior? And here we're not talking about the use many governments make of psychiatric rhetoric to justify imprisoning, sterilizing, or otherwise victimizing people they don't happen to like.  These are very important issues, and raise serious questions to ask of our highly funded social science community.

And indeed none of this is new.  A paper published in Science in 1973, called "On Being Sane in Insane Places",  is a famous and still relevant critique of psychiatric diagnosis. You can hear a quick description of this on the BBC radio program Witness here.  Briefly, Rosenhan wondered if sane people admitted to psychiatric hospitals could be distinguished from the insane context in which they were found.  He had 8 people gain admittance to 12 different hospitals, saying they'd been hearing voices, but then acting completely normal -- that is, sane -- throughout their stay.

Each 'pseudopatient' was diagnosed with schizophrenia, a diagnosis that was never questioned and each was discharged with "schizophrenia, in remission."  Other patients often questioned the diagnosis, telling the pseudopatients that they were clearly sane, or asking if they were professors checking up on the hospital or some such, but the staff never questioned the diagnosis, or declared the person sane.  Granted, hearing voices can be an indication of mental illness, and most people we'd consider sane don't hear voices, so it's no surprise that the fact that the pseudopatients had this on their record did mean something to the staff, and rightly so unless they were to be expected to doubt all reports of symptoms.

But perhaps the more interesting aspect of this story is that once news of this experiment got around, staff at various hospitals asked Rosenhan to challenge them by sending more sane patients.  Many staff members claimed to have identified numerous such patients, when in fact Rosenhan had sent none. 

Rosenhan began his paper thus: "If sanity and insanity exist, how shall we know them?"  Granted, he carried out this experiment before the biologizing of behavior became the norm, at a time when schizophrenia was said to be a "sane response to an insane world" (R.D. Laing) and so on. In fact, in the same paper, 40 years ago, he wrote about it being not uncommon for psychiatrists for the defense in a murder trial to contradict psychiatrists for the prosecution.

Further,

To raise questions regarding normality and abnormality is in no way to question the fact that some behaviors are deviant or odd. Murder is deviant. So, too, are hallucinations. Nor does raising such questions deny the existence of the personal anguish that is often associated with "mental illness."  Anxiety and depression exist. Psychological suffering exists. But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than many believe them to be.

Indeed Rosenhan's question of how we'll know sanity still stands, and we now know that biologizing the answer does not help.

An end of June broadcast, now a podcast of Thinking Allowed on the BBC included a discussion of the sociology of evil.  A question that interested us was whether one must empathize with a killer's motives in order to understand their actions.  That is, do we need to feel Breivik's motives before we can understand why he did what he did?  And thus, before we can determine his sanity?  Would that mean that if we can empathize with his motives we'd consider him sane, and if we can't we'd consider him insane? And do we screen jurors based on their views of this?

The last 40 years have brought the goal of biologizing, including geneticizing behavior -- all behaviors, not just aberrant ones -- as though we can find objective measures of insanity.  So, what does it mean if we can locate a biological explanation for Breivik's actions, if, say, we can determine that his neuronal circuitry went awry?  Say he was unable to empathize with his victims because he was genetically or otherwise mis-wired, would that mean that he can't be held responsible for his actions?

If sanity is not as objective a concept as we like to think, or is socially fluid, then how is it we spend so much effort to find the genes 'for' psychiatric disorders?  Clearly behavior has relation to genetic variation, but just as clearly we have problems on our hands that need to be taken vastly more seriously than they are nowadays.

Science may eventually be able to answer the question of circuitry -- assuming it can define 'normal' -- but the question of assigning responsibility for one's actions, of deciding when a common behavior, such as pedophilia seems to be, is criminal or a psychiatric disorder, whether actions are evil, and whether you do or must feel empathy for them, and so forth are all societal questions that science can't resolve.