Peter Barglow, MD

[[{"type":"media","view_mode":"media_crop","fid":"39891","attributes":{"alt":"Â© Photographee.eu/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_4506869573117","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4025","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 89px; width: 150px; float: right;","title":"Â© Photographee.eu/Shutterstock.com","typeof":"foaf:Image"}}]]Eight young men, one of them married, who lived near a small neighborhood by Lislebyveien Street in Fredrikstad, Norway (population 76,000), became jihadists; several of them died in Syria. A 

 on April 5, 2015, raises a “puzzling question” about this youthful cohort

: “Why is it that certain towns, and even small areas within them, generate a disproportionate number of Jihadists?” The first answer to the question is that the antisocial behavior of the members of this youthful group originates not in Norway’s indigenous small community roots, but in their history of parental immigration. The second is that terrorist actions are a product of psychological influences shared with a sizable population of young males who reside in many different countries.

Their radicalization and violent murderous hatreds represent and reflect an emotional solution of an aberrant “identity development of adolescence.”

 My answers explain the overt group behaviors that characterize a category of young persons whose actions and values appear to deviate markedly from those of the mainstream inhabitants of their civilized communities. (I try not to use psychopathological terms, a process we psychiatrists sometimes applied to characterize the 9/11 New York World Trade Center terrorists.)

Let’s assess the ethnic backgrounds of members of this collection of terrorists, all of whom were associated with the Norwegian radical Islamic group, Prophet’s Ummah.

What is striking about this group of 8 men (and the wife of one of them) is that a minority of its members has familial roots in Norway. One Norwegian member appears to be mentally ill while currently hospitalized, and another, Yousef Assidiq has turned against Jihad. All the young men are in their mid-twenties. Longitudinal neuroimaging studies demonstrate that physically normal young adults who have gone through a normative large brain reorganization between the ages of 12 and 17 may still be adjusting to these changes in their twenties (I. Feinberg, personal communication, 2015). In general, almost all have evidence of a history of social turmoil beginning with adolescence: substance abuse (marijuana), scholastic failure, delinquency, minor criminality, brushes with the law, and familial turmoil. Their socioeconomic status was clearly lower than that of Norwegian peer families. Most of the young men also had a history of addictive drug misuse. The poverty-ridden, downtrodden background of these children of immigrants is a striking contrast with the saga of a 23-year-old Egyptian Muslim bodybuilder from a wealthy family who died while fighting with ISIS in December 2014.

 in the US and other Western countries proves that the teens and early twenties are the ages associated with the highest probability for “emergence of risk-taking activity” with great potential for “antisocial, norm breaking, and criminal behavior, particularly for boys.”

 Violence and criminality are often used to cope with poverty, a harsh home life, neighborhood chaos, and brutality.

This type of environment characterized the early childhood years of the perpetrators of the 

 Poor schools, the absence of positive parental models, and a dearth of employment possibilities serve to justify gang and cult participation. Immigrant youths are often ostracized by mainstream peers and suffer massive self-esteem deficits that interfere with conventional paths of moral development. Radical ideology and participation in ostracized and stigmatized religious cults in these instances serve as an attractive pathway to a profound new but aberrant post-adolescent identity.

But the members of the Norway group also share exaggerations of many normative emotional traits of adolescence: episodes of grandiosity and a sense of invulnerability, poor anticipation of danger, impulsivity, rebellion, drug seeking, poor sense of time, and frequent self-esteem fluctuations. In particular, young men are preoccupied with the strengths of the immature physique. Perceptions of dangerous bodily weakness may elicit compensatory grandiose actions.

The advanced pulmonary tuberculosis of Gavrilo Princip, age 19, may have been a significant factor motivating his assassination of Archduke Ferdinand in Sarajevo, Bosnia, 

 Unfamiliar bodily sensations and doubts of physical deficiency and/or inferiority can also be mastered by adolescent boys’ strenuous physical athletic activity that may mask a fear of effeminate traits in themselves and a phobic avoidance of females.

There is a suggestion of an interaction between sports and the training for radical terrorism through participation in competitive games. Athletics played an important developmental role with the suicide bombers (ages 16 to 23) from poverty-ridden Sidi Moumen, Morocco, who killed 45 persons in Casablanca in 2003.

A sustained effort to apply athletics constructively is artistically captured by the 2012 French film 

, which highlights the important meaning of soccer for its 2 fictional adolescent terrorists.

 The movie also elaborates another characteristic adolescent emotional dynamic-the pivotal influence of brotherhood to concretize radical, often omnipotent, violence not acceptable in broader civilized communities.

Of course, brothers, no matter how similar they are, need not reinforce each other in performing murderous acts toward a common perceived enemy: in some cases, the enemy is the other. The story of Cain and Abel describes hatred of one brother for another. In the Greek play 

, Aeschylus dramatized the hatred between the twins Eteocles and Polynices who fulfill the curse of Oedipus by killing each other.

One brother may be peaceful and the other murderous. Earlier this year, a radicalized Islamic man of 19 murdered 21 foreign tourists and a police officer at the National Bardo Museum in Tunis. One of his older brothers is a student of philosophy who 

 for the killings. The brothers had the same upbringing, growing up in an impoverished southwest Tunisian village.

Brothers have the same genetic makeup, legacies of parenting, and personality similarities, and they share important childhood experiences sometimes producing exquisite empathic mutuality that is transformed into a folie Ã  deux merger. The “brotherhood” concept has often been borrowed and exploited for political purposes. For example, in the US, the Aryan Brotherhood is a designation adopted by a white supremacist prison gang.

One sequence of normative developmental tasks during adolescence is “identity versus role confusion,” which 

 summarizes as: “From all possible imaginable relations the adolescent must make a series of ever-narrowing selections of personal, occupational, sexual and ideological commitments.” Unresolved choices result in identity diffusion. Attainment of ethnic identity in minority-group adolescents is particularly arduous and complicated.

These children have several favorable successful possibilities for integrating their ethnicity into their larger sense of self. They may assimilate by adopting the majority culture’s norms, they may choose not to assimilate and only interact with persons from their native country, or they may become bicultural.

 But failure to travel any of these pathways when magnified by a brutal socio-psycho-economic environment may produce personality fragmentation and serious identity diffusion. (I am unable to judge the truth of Erikson’s formulations for adequate or deviant adolescent development but find them most apt to explain the genesis of the determined Norwegian youthful terrorists.)

Adoption of a radical, violent, destructive ideology is the emergency solution that I propose was used by most of the Norwegian converts to the Prophet’s Ummah. Their radicalization produced massive and terrible social consequences. The explanations I offer may be pertinent to the current attraction that ISIS offers for too many young persons in many countries of the civilized world.

Dr Barglow is a Clinical Professor of Medicine and Psychiatry at the University of California Davis School of Medicine in Sacramento. He has written numerous articles about emotional consequences of severe trauma for soldiers and war veterans, rape survivors, traumatized children, and victims of other violence. He reports no conflicts of interest concerning the subject matter of this article.

 Higggins A. A Norway town and its pipeline to Jihad in Syria. 

. April 4, 2015. http://www.nytimes.com/2015/04/05/world/europe/a- norway-town-and-its-pipeline-to-jihad-in-syria. html. Accessed May 26, 2015.

Identity Development: Adolescence Through Adulthood

. 2nd ed. Thousand Oaks, CA: Sage Publications; 2007.

 Arnett JJ. Adolescent storm and stress, reconsidered. 

 Chrisafis A. Charlie Hebdo attackers: born, raised and radicalised in Paris. 

. January 12, 2015. http://www.theguardian.com/world/2015/jan/ 12/-sp-charlie-hebdo-attackers-kids-france- radicalised-paris. Accessed May 26, 2015.

 Weissman SH, Busch KG, Schouten R. The evolution of terrorism from 1914 to 2014. 

 Gall C. In Tunisia, one brother studied philosophy, another gunned down tourists. 

. April 2, 2015. http://www.nytimes.com/2015/04/03/ world/africa/in-tunisia-one-brother-studied- philosophy-another-gunned-down-tourists.html. Accessed May 26, 2015.

. New York: WW Norton & Company, Inc; 1968:146.

 Phinney JS. Stages of ethnic identity development in minority group adolescents. 

Articles

Radicalization by Norwegian converts to the Prophet’s Ummah produced massive and terrible social consequences. The explanations offered may be pertinent to the current attraction that ISIS offers for too many young persons in many countries of the civilized world.

Immigration and Post-Adolescent Psychology of Young Terrorists

Currently the Veterans Administration (VA) is the world’s largest recipient of per patient funding for PTSD. The VA treats 200,000 veterans with this diagnosis annually at a cost of $4 billion. But research calls into question the very existence of the “PTSD” syndrome, and its diagnostic formulation remains invalid. We do not minimize the suffering of those who experience trauma or the need for comfort and restitution. We seek only to reexamine research evidence, to clarify the impact of culture on diagnosis, to reevaluate the consequences of trauma, and to ensure optimal allocation of resources.

The 1980 edition of DSM (DSM-III) included PTSD after lobbying by antiwar psychiatrists, Vietnam veterans’ organizations, social workers, and psychologists.1 According to Scott,2 these advocates argued that traumatic memories of war were reemerging in more virulent form as PTSD. This perspective focused on the aftereffects of war rather than the psychodynamics of individual patients.3 It was assumed that an organic brain change had occurred secondary to the psychological arousal of stress. A second assumption was that those treated would become chronically disabled.

The American Psychiatric Association (APA) started by using the military’s diagnostic criteria. The DSM-IV sourcebook contains the empirical evidence used to create categories of disorders.4 The decision-making process is complex, and human judgment is required to create diagnoses. APA researchers responded to criticism of the way PTSD was formulated by making changes: 11 in the 1987 revision of DSM-III-R, and 15 in the 1994 DSM-IV edition.5 Today there are almost 200 combinations of symptoms through which PTSD can be diagnosed.

The PTSD symptom profile overlaps with those of common mental conditions, such as mood disorders, anxiety disorders, and substance abuse. A 1995 survey reported that 88% of men and 79% of women with a diagnosis of PTSD had at least 1 comorbid diagnosis.6 Major depression, the most common comorbidity, was diagnosed in almost 50% of patients with PTSD. That the PTSD cluster incorporates many nonspecific indicators of psychiatric distress found in other common psychiatric conditions calls into question the validity of the diagnostic category.

There is a more fundamental problem: PTSD symptoms may not be linked to trauma. Bodkin and colleagues7 showed that among those for whom pharmacological treatment of major depression was considered, patients with and without a trauma history met the diagnostic criteria for PTSD at identical rates (78%). Gold and coworkers8 showed that college students without a traumatic experience were more likely to meet the other diagnostic criteria of PTSD. In 1988, the National Vietnam Veterans Readjustment Study found that 30.9% of Vietnam veterans had full-blown PTSD-but only 15% of these vets had been assigned to combat units.9 Analyses using narrower diagnostic criteria and verified reports of trauma exposure reported rates from 2.9% to 15.5%.10

Subjective symptoms and financial benefit suggest that secondary gain plays a role in PTSD diagnoses. One of us (PB) in 2000 reviewed the medical records of 90 patients with a primary PTSD diagnosis treated in a VA outpatient clinic. Records showed a uniformity and consistency in key words and subjective reports. Such a repetitive quality might reflect precise diagnostic criteria and reliability among diagnosticians; it could also reflect expectancies and elicitation of key descriptions by examiners. This tendency was noted in reports of En­glish “shell shock” victims and Rus­sian “contusion” casualties during WWI, regarded as predecessors of PTSD.11 These earlier diagnoses had a different symptom constellation also characterized by uniformity. The victims shook, stuttered, limped, and showed sensory-motor signs (such as deafness, muteness, and blindness). They did not report the anger, numbing, or flashback symptoms said to characterize PTSD today. Leaders and activists in VA centers told PB that veterans were counseled (coached) on how to present to the psychiatrists determining disability benefits.

Frueh and associates12 noted that patient reports of military combat may not match military records. They found that 32% of men attending a VA outpatient combat-related PTSD clinic had no evidence of combat exposure in their military record. Elhai and colleagues13 reported that compensation-seeking veterans were more likely  to overreport and exaggerate PTSD symptoms. A 2005 report from the VA Office of Inspector General noted that veterans’ PTSD symptoms became more severe until their compensation reached the 100% disability level.14 Thereafter, there was an 82% drop in the use of VA mental health services but no change in the use of other medical services.

In summary, the current diagnostic criteria for PTSD are unsatisfactory because:

• It is difficult to distinguish between the PTSD symptom cluster and what could be considered a normal human response to massive trauma.
 • PTSD, generalized anxiety disorder, depressive disorder, and substance dependence are difficult to separate.
   Symptoms that define PTSD  are not strongly correlated with trauma.
 •  The diagnosis of PTSD relies on unverified trauma and subjective reports of symptoms.
 • Financial compensation is an important reinforcing factor suggesting secondary gain.

1. Baldwin SA, Williams D, Houts AC. A case study in critical psychopathology. The Scientific Review of Mental Health Practice. 2004;3:33-57.
2. Scott W. PTSD in DSM-III: a case in the politics of diagnosis and disease. Social Problems. 1990;37: 294-310.
3. Jones E, Wessely S. A paradigm shift in the conceptualization of psychological trauma in the 20th century. J Anxiety Disord. 2007;21:164-175.
4. DSM-IV Sourcebook. Arlington, VA: American Psychiatric Publishing, Inc; 1994.
5. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Arlington, VA: American Psychiatric Publishing, Inc; 1994.
6. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.
7. Bodkin JA, Pope HG, Detke MJ, Hudson JI. Is PTSD caused by traumatic stress? J Anxiety Disord. 2007;
21:176-182.
8. Gold SD, Marx BP, Soler-Baillo JM, Sloan DM. Is life stress more traumatic than traumatic stress? J Anxiety Disord. 2005;19:687-698.
9. McNally RJ. Can we solve the mysteries of the National Vietnam Veterans Readjustment Study? J Anxiety Disord. 2007;21:192-200.
10. Kulka RA, Schlenger WE, Fairbank JA, et al. National Vietnam Veterans Readjustment Study (NVVRS): description, current status, and initial PTSD prevalence estimates. Research Triangle Park, NC: Research Triangle Institute; 1988.
11. Barglow P, Bowman M, Friedlander J. Is post-traumatic stress disorder a valid psychiatric diagnosis? The Scientific Review of Alternative Medicine. 2006;
10:36-44.
12. Frueh BC, Elhai JD, Grubaugh AL, et al. Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder. Br J Psychiatry. 2005;186:467-475.
13. Elhai JD, North TC, Frueh BC. Health service use predictors among trauma survivors: a critical review. Psychol Serv. 2005;2:3-19.
14. Department of Veterans Affairs Office of Inspector General Report No. 05-00765-137. Washington, DC; 2005. http://thomas.loc.gov/cgi-bin/cpquery/?&sid=
cp1095TraP&refer=&r_n=hr305.109&db_id=109&
item=&sel=TOC_60057&. Accessed June 10, 2009.

Peter Barglow, MD

Articles

Immigration and Post-Adolescent Psychology of Young Terrorists

PTSD Has Unreliable Diagnostic Criteria