The vast majority of mentally ill people are of no risk to the rest of the population. Individuals with psychiatric problems are frequently anxious, withdrawn, shy and avoidant. They are hardly individuals likely to engage in threatening behavior. I raise this observation because now emerging is the possiblitly that Norway’s mass killer, Anders Behring Dreivik, is mentally ill.

As surprising as it seems to us in the Australian legal context, his lawyer is giving the Norwegian public a running commentary on his client’s beliefs and attitudes towards his disastrous actions. The information raises the possibility that Breivik is delusional with paranoid and grandiose themes, and operating within a great conspiracy generated in his mind. He may also have been under the influence of stimulants or other drugs at the time of his carnage.

But other explanations need to be considered. He may be an unusual personality with an eccentric and paranoid (but not psychotic) view of the world. These individuals are often reclusive, suspicious, distant or aloof, and have odd beliefs and behavior, and magical thinking. Or he may be an antisocial and narcissistic psychopath with scant regard for the rights of others, and with a callous, self-righteous and entitled approach to the world. Empathy and remorse would be foreign to this type of person. Or there may be little in the way of psychiatric insights into his behavior – in this case the term “evil” might best apply.

Judgments about his capacity to have been responsible for his actions will no doubt be decided in the Norwegian justice system in due course.

While the combination of psychosis, substance abuse and antisocial personality can be associated with dangerous behaviors, fortunately this applies to only a tiny proportion of individuals suffering from mental illness.

Norway has been traumatized by this event. So far, 76 people have died – many just entering the gateway to adult lives. Others are survivors of the slaughter – either escaping the blast in Oslo or the shootings at the island camp. When one considers the family, friends, associates and colleagues of each of these individuals would number into the hundreds, it is clear to see that in a nation of about five million, a significant proportion of the population has been directly affected by this tragedy.

The nation and individuals affected by this traumatic loss will be feeling fear, guilt, sadness and anger, and will be asking “why?” – a question not easily answered. Following the initial shock is the reaization of loss with associated feelings of post-traumatic stress and intense grief. Support services should be registering the names of survivors and those who have lost loved ones so that follow-up arrangements can be made to provide assistance and monitor recovery.

Initial help will provide “the basics” – safety, food, shelter, medical care – and connecting affected indeividuals with natural supports – family, friends, and church and other community caring services. Information and education of the community and of victims will be provided to make sure people know what to expect, what are “normal” and other reactions to the devastating circumstances, and when and how to get further help.
For all individuals affected, life will never be the same. But for most. the intense distress will fade and recovery will gradually build. Unfortunately, a small but significant proportion of survivors and those bereaved will remain emotionally unwell. It is here that the follow-up program is essential to identify and provide early and ongoing medical and psychological assistance to these individuals and their families.

We are getting better at providing effective support in disaster situations – in part because we are becoming more practiced (recently with the south-east Queensland floods; cyclone Yasi; the Christchurch, New Zealand earthquakes; and the tsunami in Japan), but we should never forget or leave behind those marked indelibly by their experiences. Over time Norway will recover. It is a resilient nation and people. But my heart goes out to all those suffering from this horrible trauma.

School of Medicine, Bond University, Gold Coast, Queensland, Australia