ideology attached to psychopathology

Guardian | Seumas Milne claims that it might be "comforting, perhaps, to dismiss Anders Behring Breivik as nothing more than a psychotic loner" (In his rage against Muslims, Norway's killer was no loner, 28 July). He thinks that this would have "the advantage of meaning no wider conclusions need to be drawn about the social context of the atrocity" – and therefore should be avoided.

Milne seems to be using an either/or grid under which a consideration of the impact of Breivik's personality prevents considerations from other perspectives.

We think that, to the contrary, the necessary conclusions can only be drawn if the assessment of Breivik's personality is not restricted along the usual and apparently comforting lines of "mad or bad". Even though we have not assessed Breivik, from the information available one could assume that he may have a severe personality disorder and that his psychopathology "attached" itself to extreme political ideology.

This manifest politicisation of his likely psychopathology seems to have facilitated a general collusion with his "delusion of sanity" (as first described by Dr Leslie Sohn, psychiatrist and psychoanalyst). This is a commonly seen phenomenon in forensic psychiatry among individuals who have committed terribly violent acts.

The equally frequent collusion is promoted by the ubiquitous wish for a rational explanation for such terrible deeds. Such an explanation can serve as a means to avoid the anxiety of imagining the state of mind of a person who reportedly laughed while shooting his victims.

In our view the assumption of a clear divide between psychosis and personality disorders in the current manuals is an unhelpful restriction. Considering psychosis and personality disorders as a single diagnostic entity enables us to opine that Breivik may well have had an undiagnosed severe personality disorder which, for years, managed to contain his conscious and likely unconscious violent fantasies.

At the time of the killings this containment might have broken down, and losing contact with reality in a psychotic state could have enabled the violent fantasies to be enacted and the catastrophic events to unfold. Later on, a more personality-disordered presentation might have become apparent once more when Breivik appeared "normal" and sane.

Going along with this appearance can cause errors in reporting such cases as predominantly political, which in turn can inhibit the chance of understanding such individuals. And at the institutional level it can lead to poor subsequent long-term management of the individual, and also to unjustified limitations on the freedom of holding political views, abhorrent though some of these might be.

Ultimately, failing to challenge but rather gratify the probable grandiose part of Breivik's disturbed mind can be of little comfort to surviving victims or relatives and friends of those killed.