Is there a role for psychiatry in deepening our understanding of the “suicide bomber”?

If it is true that Medicine is a science deeply rooted in society, there can be little doubt that Psychiatry especially is a discipline which is linked to and a reflection of social urges, demands, problems and fears, since the individual may be considered as the result of a constant interaction between the brain and its environment [1]. 

For this reason, when applied in the diagnosis, treatment and, when successful, resolution of specific disturbances or disorders, Psychiatry restores not only a deranged brain equilibrium, but, in addition, an individual’s attitudes and behaviours and, consequently, the effects that single individual may have upon society. It may equally be concluded that the particular society by which an individual is surrounded, together with any conflicts which may exist therein, can affect his or her functioning and induce mental disorders, or act as a triggering factor in those more vulnerable members of that society. It is therefore important that Psychiatry be sufficiently flexible to take into account constant inputs deriving from a rapidly changing world, which can affect or even create hitherto unknown disorders. This will be the paramount challenge of coming years and one which simply must be met successfully, since for the first time since the end of the second world war, Western societies have to cope with tragic occurrences which have significantly undermined their sense of safety, their optimistic expectation of ever-increasing benefits from technological advances and their overall trusting belief that a happy future lies ahead. 

The attack on the twin towers of September 11th 2001 and the subsequent attacks which occurred in Madrid and London demonstrated disastrously just how vulnerable to terrorism any society has now become, and that distant wars or conflicts can no longer be considered so far away as to be of no consequence. Probably there will soon be (if there is not already) endemic throughout a large part of the world a generalized sense of precariousness and awareness that a suicide bomber can act everywhere easily. Augmenting this dreadful reality is the fact that the mass media constantly show appalling images of prisoners, executions, corpses and battles, with a clarity of cruel details and insistent repetition \u0001 all in the name of ‘‘freedom of information’’ \u0001which can only result in the profound disturbance of children and adults even while ensconced in their distant and comfortable homes [2]. 

In this sense, the British choice not to show images of the terroristic attacks on London public transport is appreciable. Therefore, nowadays Psychiatry must face two major needs, deriving from the current atmosphere which now pervades the Western world. Firstly, posttraumatic stress disorder (PTSD): it is undoubtedly an increasingly prevalent pathology, especially amongst those personnel involved in combat operations [3]. However, PTSD is found nowadays even in the victims or spectators of catastrophes, mainly under the form of sub-threshold symptoms, so that it is sometimes difficult to make a focused diagnosis and, consequently, propose adequate treatment. Unfortunately, the current diagnostic systems are not set up in a way to categorize isolated or atypical symptoms, such as loss of hope and awareness of an uncertain future for our children, fears related to travel, or the faint alarm felt when meeting someone from a different culture, which can be quite upsetting. Besides PTSD, populations exposed to traumas may become susceptible at a higher-than-average risk also of developing depression, substance abuse and/or social adjustment disorders [4], and, therefore, be in definite need of prompt psychiatric help. Secondly, a more difficult task is the study of the suicide bomber’s (psycho)pathology. Published literature on this topic is still practically non-existent [5] and tends to exclude any appreciable element of psychopathology [6]. 

Our strongly held view is that this may well not be appropriate: the problem of suicide bombing has so far been debated largely from a socio-cultural, political and/or religious perspective, and the absence of any recurrent element of psychiatric disorder has generally been assumed, given of course the impossibility of any qualified psychiatric examination of the subject after the event. Although obviously there exist cultural and religious causes for this phenomenon, coupled often (although by no means always) with conditions of poverty and abandonment, these factors do not seem to be of crucial importance in determining such deviant behaviour: in fact, suicide bombers do not seem to present any particular feature which distinguishes them from other members of the society from which they come, and share with them the same life opportunities [6]. Even the broad assumption up until now that they derive mainly from young, unmarried members of the male sex has more recently been proven comprehensively false by the behaviour of women, who have shown themselves equally capable of suicidal violence, even to the point of deliberately taking children’s lives (as demonstrated so dramatically with the schoolchildren of Beslam). As a result, the increasing diffusion of the modern suicide bomber may be viewed as an appalling new phenomenon, urgently requiring new methods of analysis [7]. 

The aim of the suicide bomber is generally supposed to be that of creating a widespread sense of alarm and thus influencing a large target audience, but individual personalities and motivations remain obscure, although violent behaviours are generally performed under conditions of group pressure and charismatic leaders, or even from a sense of obligation in situations of authority [6]. In psychiatric terms, a sense of revenge (or despair, or humiliation) which is induced to a point of dominance where normal instincts for survival become sublimated to a conviction that death will somehow be rewarding, could well be judged to present elements of delusional intensity and paranoia. Alternatively, suicide bombers might conceivably be affected by double personality disorder, or, more in general, by complex personality disorders shaped by specific contexts, and rendered common by peculiar historical and social events, or victimization from violence [6]. 

A common feature of suicide bombers seems to be, in fact, experiences of familial or personal violence that may constitute the ‘‘core’’ events acting as a psychopathology organizer. If we are to succeed in identifying with any degree of reliability and depth these motivations which are inducing people to kill both themselves and others, we simply must overcome a natural sense of repugnance and begin to find the means of setting up reliable studies. Although prevalent conditions will always render any psychiatric intervention difficult in the extreme, it remains crucially important that some kind of pragmatic programme be developed for initiating a practical approach to the problem. Perhaps the key principle to establish is this: that understanding does not have to equate to agreement. All societies, in fact, stand to benefit from a population which is not deeply troubled and divided by fear, hatred or uncertainty which may be caused by pathological mental conditions (or conditioning) which, by their very definition, preclude a peaceful and contented existence for all. If psychiatrists and scientists are to work towards this goal of increased reciprocal understanding amongst both themselves and patients, they must first find a way of systematically and steadfastly removing many of the cultural, procedural and theoretical barriers currently blocking any real progress. 

The first step would be simply to discuss scientifically these specific topics, which seem to be neglected or only partially approached in the academic environments and debated only by journalists, sociologists and the general public. If serious, professionally conducted, medical and/ or psychiatric forums were to be organized, under the umbrella of ‘‘Understanding the Unacceptable’’, under the auspices of well- respected focal points of medical opinion, with the specific objective of debating the mental aspects of self-destructive terrorist activity, we do believe that there would have been created a very valuable adjunct to the different counter-efforts already being pursued, in order to divert people from becoming terrorists.

Donatella Marazziti M.D.