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\title{DSM-5 cultural and personality assessment of extreme overvalued beliefs}
\date{7 January 2021}
\author{Tahir Rahman, Lingjin Zheng, J. Reid Meloy}
\subtitle{}






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\section{ABSTRACT}


Lone actor targeted violence is often the result of pathological fixations driven by extreme overvalued beliefs. An extreme overvalued belief is shared by others in a person’s cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. Over time, the belief grows more dominant, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service. The belief becomes increasingly binary, simplistic, and absolute. We discuss the phenomenology, historical origins and application of extreme overvalued belief which was derived from the seminal work of the 19th century German neuropsychiatrist, Carl Wernicke. We discuss how delusions are different from extreme overvalued belief. Targeted violence motivated by political, religious, racial, sexual or other shared ideologies, and often fueled through online interaction are discussed and applied to well known cases, including Anders Breivik, the Unabomber, assassins such as John Wilkes Booth, Osama bin Laden, Incels, anti-LGBTQ, Sovereign Citizens, violent jihadists, and neoNazis. The DSM-5 models on cultural formulation and alternative personality disorder are presented here as important contributions to clearly understanding cases involving extreme overvalued beliefs.

\section{Keywords}


Lone actor targeted violence Terrorism


Extreme overvalued beliefs Countering violent extremism Ideology


Assassinations

\section{Funding Statement}


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

\section{About the Authors}


Tahir Rahman


\emph{Washington University in St. Louis, School of Medicine, United States of America}


\emph{E-mail address:} \href{mailto:trahman@wustl.edu}{trahman@wustl.edu} (T. Rahman).


Lingjin Zheng


\emph{Washington University in St. Louis, School of Medicine, United States of America}


J. Reid Meloy


\emph{University of California, San Diego, School of Medicine, United States of America}

\chapter{1. Introduction}


Many acts of terrorism, mass murder and hate crimes are motivated by \emph{extreme overvalued beliefs}. An extreme overvalued belief is shared by others in a person’s cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. Over time, the belief grows more dominant, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service (\href{\#\_bookmark50}{T. Rahman, 2018}). The belief becomes increasingly binary, simplistic, and absolute. This definition was first described in response to a case analysis of Norwegian terrorist Anders Breivik by our team of forensic researchers at an \emph{American Academy of Psychiatry and the Law} annual conference and is now a part of threat assessment and management (\href{\#\_bookmark52}{T. Rahman et al.,} [2020]). Breivik was responsible for the bombing and mass shooting deaths of 77 mostly young people in Norway in July 2011, and his insanity trial sparked a controversy surrounding his diagnosis. Prior to his attacks, Breivik released a compendium entitled, “2083: A European Declaration of Independence,” in which he opposed multiculturalism, Marxism, and the Norwegian Labor Party. He also referred to himself as a “Knight Templar,” raising concerns that he held delusions from a possible diagnosis of schizophrenia. However, the insanity defense was ultimately rejected, and the court found that he held beliefs shared by other right-wing extremists, and not delusions from a psychotic mental illness (Melle, 2013 T. Rahman, Resnick, \& Harry, 2016). Utilizing the historic work of neuropsychiatrist Carl Wernicke (also known for his work on aphasias), our forensic research identified Breivik’s fixation as matching Wernicke’s classic description of beliefs that are shared by others, called overvalued ideas (\href{\#\_bookmark54}{T. Rahman et al., 2016}; \href{\#\_bookmark52}{T. Rahman} \href{\#\_bookmark52}{et al., 2020}; \href{\#\_bookmark62}{Weiss, 2016}).


\emph{Fixation} has been identified as an important proximal warning behavior in lone actor terrorism (\href{\#\_bookmark36}{J.R. Meloy, 2017}; \href{\#\_bookmark39}{J.R. Meloy \& Hoff-} \href{\#\_bookmark39}{mann, 2014}; \href{\#\_bookmark46}{Mullen et al., 2009}). It indicates an increasingly pathological preoccupation with a person or a cause, accompanied by a deterioration in social and occupational functioning (\href{\#\_bookmark37}{J.R. Meloy \& Gill,} [2016]; \href{\#\_bookmark42}{J.R. Meloy, White, \& Hart, 2013}). \emph{Extreme overvalued belief} has emerged as an important cognitive-affective driver of fixation responsible for violence motivated by political, religious, racial, sexual or other shared ideologies, often fueled through online interaction (\href{\#\_bookmark52}{T.} \href{\#\_bookmark52}{Rahman et al., 2020}). In addition to Breivik, other well-known events and offenders that implicate extreme overvalued beliefs include the 9\Slash{}11 attacks, Unabomber (Ted Kaczynski), Oklahoma City bombing, Boston Marathon attack, Elliot Rodger (INCELs), Dylan Roof (hate crime), political assassinations, as well as other types of group and lone actor attacks (\href{\#\_bookmark41}{J.R. Meloy \& Rahman, 2020}; \href{\#\_bookmark53}{T. Rahman, Meloy, \& Bauer,} [2019]). Online extremist subcultures, highlighted by recent attacks from involuntary celibates (INCELs), neoNazis, white supremacists, radical jihadists, and Sovereign Citizens are part of a growing threat to society. This definition, rooted in the psychiatric literature, has been studied by forensic experts and recommended for inclusion in future editions of the DSM-5 to highlight the fact that extreme overvalued beliefs are \emph{shared} by others in their culture or subculture (\href{\#\_bookmark5}{Arief} \& Karlinah, 2019; \href{\#\_bookmark14}{Cunning-} \href{\#\_bookmark14}{ham, 2018}; \href{\#\_bookmark16}{Freudenreich, 2020}; \href{\#\_bookmark24}{Karandikar, 2019}; \href{\#\_bookmark28}{M.H. Logan, 2014,} [2018]; \href{\#\_bookmark41}{J.R. Meloy \& Rahman, 2020}; \href{\#\_bookmark43}{Misiak et al., 2019}; \href{\#\_bookmark50}{T. Rahman,} [2018]; \href{\#\_bookmark54}{T. Rahman et al., 2016}; \href{\#\_bookmark53}{T. Rahman et al., 2019}; \href{\#\_bookmark52}{T. Rahman et al.,} [2020]; \href{\#\_bookmark51}{T. Rahman, Grellner, Harry, Beck, \& Lauriello, 2013}; \href{\#\_bookmark55}{C.M. Sar-} \href{\#\_bookmark55}{teschi, 2016, 2018}; \href{\#\_bookmark62}{Weiss, 2016}). This differentiates extreme overvalued beliefs from delusions or obsessions, and can be easily and reliably separated from them (see \href{\#\_bookmark3}{Table 1}) (\href{\#\_bookmark41}{J.R. Meloy \& Rahman, 2020}; \href{\#\_bookmark52}{T.} \href{\#\_bookmark52}{Rahman et al., 2020}).


The definition of \emph{overvalued idea} in the DSM-5 differs from \emph{extreme overvalued belief} because the latter requires that the belief is shared by others in an individual’s culture or subculture (\href{\#\_bookmark4}{American Psychiatric} \href{\#\_bookmark4}{Association, 2013}; \href{\#\_bookmark52}{T. Rahman et al., 2020}) . We will begin our discussion by explaining the phenomenology and three cognitive-affective drivers of fixations (delusion, obsession and extreme overvalued beliefs), and we will apply the concept of \emph{extreme overvalued beliefs} to cases of targeted violence. Finally, we will use the DSM-5 cultural and personality models to better understand how extreme overvalued beliefs are amplified from “normal-valuedness” to “overvalued-ness.” (\href{\#\_bookmark4}{APA, 2013}).

\chapter{2. Phenomenology}


\textbf{Table 1}


The three cognitive-affective drivers of fixation (\href{\#\_bookmark41}{J.R. Meloy \& Rahman, 2020}; \href{\#\_bookmark52}{T.} \href{\#\_bookmark52}{Rahman et al., 2020}).

\bigskip
\noindent
 \begin{minipage}[t]{\textwidth}
\begin{tabularx}{\textwidth}{|X|X|}
\hline
\relax  Delusion  &  A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not ordinarily accepted by other members of the person’s culture or subculture (i.e., it is not an article of religious faith) ( \href{\#\_bookmark4}{Association, 2013}).   \\
\relax  Extreme overvalued belief  &  A belief that is shared by others in a person’s cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. The belief grows more dominant over time, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service (T. Rahman, 2018).   \\
\relax  Obsession  &  Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted and that in most individuals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, images, or to neutralize them with some other thought or action (i.e., by performing a compulsion) (Association, 2013).   \\
\hline
\end{tabularx}
\end{minipage}
\bigskip


Although often triggered by environmental stressors, delusions and obsessions are currently viewed as brain diseases (in which something is “broken” in the brain) (\href{\#\_bookmark50}{T. Rahman, 2018}). Extreme overvalued beliefs, by contrast, emphasize the \emph{shared} nature of some types of beliefs. They spring from strong affective experiences and are felt as “normal” by the individual, such as passionate political, religious, sexual or ethical conviction (\href{\#\_bookmark53}{T. Rahman et al., 2019}). They may be marked by several warning signs prior to an attack, such as a noticeable increase in perseveration, strident opinion, negative statements about the target(s), increasing anxiety or fear about the target, and an angry emotional undertone (\href{\#\_bookmark51}{T. Rahman et al., 2013}; \href{\#\_bookmark53}{T. Rahman et al., 2019}; \href{\#\_bookmark52}{T. Rahman} \href{\#\_bookmark52}{et al., 2020}). Eating disorders, usually seen in young women and girls, while having important biological underpinnings, are also driven by overvalued, often shared cultural beliefs (i.e. to be thin and more desirable) (\href{\#\_bookmark41}{J.R. Meloy \& Rahman, 2020}; \href{\#\_bookmark45}{Mountjoy, Farhall, \& Rossell,} [2014]; \href{\#\_bookmark53}{T. Rahman et al., 2019}). We will expand on this when discussing body ideals held by members of the involuntary celibate community (INCEL) related to violence (\href{\#\_bookmark65}{White, 2017}).

\chapter{3. Historical origins}


Carl Wernicke and Sigmund Freud were both students of GermanAustrian neuropathologist Theodor Meynert. While studying with Meynert, Wernicke formulated his theory of localized lesions in the brain involved in aphasias. He is honored by having the sensory area of the brain named after him (Wernicke’s area in the left temporal lobe). He also first coined the term \emph{uberwertige} \emph{Idee} (overvalued idea), in the context of criminality in an 1892 German medical journal (\href{\#\_bookmark63}{C. Wernicke,} [1892]). He later authored a psychiatric textbook, \emph{Grundriss} \emph{der Psychiatrie} \emph{in klinischen Vorlesungen} (\emph{Outline of Psychiatry}) and applied the concept of overvalued idea to Dostoevsky’s novel \emph{Crime and Punishment} (\href{\#\_bookmark11}{Burn-} \href{\#\_bookmark11}{ham, 2002}; \href{\#\_bookmark64}{C. Wernicke, 1906}). The novel’s protagonist, Rodion Raskolnikov, is an impoverished former law student in Saint Petersburg who develops an overvalued idea as a motive to kill an unscrupulous elderly pawnbroker. Raskolnikov, in his manifesto, identifies with individuals like Napoleon Bonaparte. Wernicke argues that Raskolnikov held overvalued beliefs of making “exceptional contributions to humanity,” and thus he had the right to break the law, including murder, in a “morally justified” pursuit of making exceptional contributions (\href{\#\_bookmark53}{T. Rahman et al.,} [2019]; \href{\#\_bookmark64}{C. Wernicke, 1906}). Wernicke goes on to assert that overvalued ideas are ideas that influence behavior to a pathological degree. The change from “normal valued-ness” to “overvalued-ness” occurs because of a particularly affect-laden experience, or a series of such experiences. Normally, countervailing ideas balance the influence an idea has on determining behavior, and a lack of such balancing can allow beliefs to become overvalued (\href{\#\_bookmark63}{C. Wernicke, 1892, 1906}). Descriptive psychopathologic definitions were implemented by psychiatry to form the scientific basis emphasizing the \emph{form} of symptoms (e.g. hallucinations, delusions, obsessions and overvalued ideas), rather than just their \emph{content.} Wernicke also stated that the content of an overvalued belief can be anything. This poses a challenge to acquire information in any individual case, and also explains why there is no particular disorder (e.g. major depression, antisocial personality, etc) to account for the spectrum of diagnoses among targeted attackers.


Emil Kraepelin (1856–1926), Karl Jaspers (1883–1969), Carl Wernicke (1848–1905) and Sigmund Freud (1856–1939) and others were instrumental in shaping modern neuropsychiatric definitions (\href{\#\_bookmark17}{Gelder}, \href{\#\_bookmark17}{Gath, \& Mayou, 1989}; \href{\#\_bookmark23}{Jaspers, 2013}; \href{\#\_bookmark47}{Oyebode, 2008}; \href{\#\_bookmark67}{G. Winokur \&} \href{\#\_bookmark67}{Clayton, 1994}). French psychiatrists also noted that delusions can be shared by others (\emph{folie} \emph{a}` \emph{deux}, “insanity of two”). It classically involves the transmission of delusional symptoms from a psychotic individual (the dominant, or index case) to a more suggestible party (the secondary case). Secondary cases tend to be more gullible and passive, with dependent traits. The shared delusion is usually within the limits of possibility, and the degree of impairment is generally less severe in the secondary case. Separation from the primary case can be both therapeutic and diagnostic if the delusions dissipate (\href{\#\_bookmark51}{T. Rahman et al., 2013}). The newer term, extreme overvalued belief, is more concise than \emph{folie} \emph{a`deux} because it clarifies that the beliefs are not due to a delusion or obsession. Wernicke’s classic description of overvalued idea highlights the underpinnings of fixation, including correlates found in modern threat assessment tools, such as personal grievance, moral outrage, ideological framing, and changes in thinking and emotion in the Terrorist Radicalization Assessment Protocol (\href{\#\_bookmark36}{J.R. Meloy, 2017}).


Furthermore, lone actor offenders, like Raskolnikov are often solitary by nature, and may have an “internal struggle”, and begin to identify with being a “warrior” for a cause (\href{\#\_bookmark39}{J.R. Meloy \& Hoffmann, 2014}). Wernicke’s description of such an internal struggle is similar to the spiritual struggle espoused by some members of Islamic inspired subcultures of terrorism, the Involuntary Celibates (INCELs), the Boston marathon attackers (Tsarnaev brothers), the Fort Hood attacker (Nidal Malik Hassan), the underwear bomber (Umar Farouk Abdulmutallab) and others (\href{\#\_bookmark10}{Bo¨ckler, Hoffmann, \& Meloy, 2017}; \href{\#\_bookmark13}{Cotti \& Meloy, 2019}; \href{\#\_bookmark18}{Gill, 2015}; \href{\#\_bookmark40}{J.} \href{\#\_bookmark40}{R. Meloy \& Mohandie, 2014}; \href{\#\_bookmark41}{J.R. Meloy \& Rahman, 2020}; \href{\#\_bookmark38}{Meloy, 2018}).


Overvalued ideas are usually seen in clinical settings such as in anorexia nervosa, parasitophobia (e.g., Ekbom’s syndrome or delusional parasitosis), body dysmorphic disorder, and hypochondriasis. These disorders have shared, intense beliefs associated with them which can develop into maladaptive behavior (\href{\#\_bookmark17}{Gelder} et al., 1989

% [[\#\_bookmark47][Oyebode, 2008]]; [[\#\_bookmark51][T. Rahman et al., 2013]]; [[\#\_bookmark53][T. Rahman et al., 2019]]; [[\#\_bookmark52][T. Rahman et al., 2020]]; [[\#\_bookmark60][Veale, 2002]]; [[\#\_bookmark66][G. Winokur, 1977]]). Indeed, such body image distortions have also been seen in members of the INCEL subculture, in which individuals share an ideology based on an inability to find a romantic sexual partner. Again, it is the form of the belief (overvalued) that is the same, but with vastly different contents (body image, religious, political, etc.).
\chapter{4. Osama bin Laden and Al-Qaeda}


On September 11, 2001, nearly 3000 individuals perished in the deadliest terrorist attack in United States history. The attacks were a series of four coordinated hijacked passenger jets by 19 Al-Qaeda terrorists. The attacks were masterminded by Osama bin Laden. Under his leadership, Al-Qaeda was the organization responsible for many other mass-casualty attacks worldwide. Bin Laden espoused many antiSemitic and anti-Western beliefs. His central motivating extreme overvalued belief was that U.S. foreign policy has oppressed, killed and harmed Muslims in the Middle East. His moral justification can be seen in some of his rhetoric:



\begin{quote}


What the United States tastes today is a very small thing compared what we have tasted for tens of years. Our nation has been tasting this humiliation and contempt for more than 80 years. Its sons are being killed, its blood is being shed, its holy lands are being attacked, and it is not being ruled according to what God has decreed. Despite this, nobody cares


(Goertzel, 2002, p. 107)



\end{quote}


Bin Laden subscribed to a literal interpretation of Islam including Sharia law. He called upon Americans to convert to Islam and reject immoral acts. In 1998, he and Ayman al-Zawahiri co-signed a fatwa in the name of the World Islamic Front for Jihad against Jews and Christians, declaring that “it is the duty of every Muslim to liberate the al-Aqsa Mosque in Jerusalem and the holy mosque in Mecca from their grip.” Bin Laden and other followers of radical Islamic extremist ideologies adhere to extreme overvalued beliefs. As seen with the 9\Slash{}11 hijackings, terrorists can think rationally, but they do so within the limits of belief systems that are irrational to outsiders, rigid, simplistic, and defended with great emotional intensity (Goertzel, 2002). As Post (2001) observed:]]


Considering the diversity of causes to which terrorists are committed, the uniformity of their rhetoric is striking. Polarizing and absolutist, it is a rhetoric of “us vs them.” It is rhetoric without nuance, without shades of gray. “They,” the establishment, are the source of all evil in vivid contrast to “us,” the freedom fighters, consumed by righteous rage. And, if “they” are the source of our problems, it follows ineluctably in the special psycho-logic of the terrorist, that “they” must be destroyed. It is the only just and moral thing to do. Once one accepts the basic premises, the logic reasoning is flawless (p. 98).]]


Indeed, the beliefs of terrorists, like bin Laden, are relished, amplified, and defended by their possessors. Over time, the belief grows more dominant, more refined, and more resistant to challenge. Individuals belonging to Al-Qaeda have an intense emotional commitment to the belief and are very willing to carry out morally reasoned violent behavior from within the belief, such as flying airplanes full of innocent passengers into buildings full of innocent people in its service (T. Rah- man, 2018).]]

\chapter{5. Sovereign citizens}


Although the threat posed by radical jihadists remains, U.S. law enforcement ranks sovereign citizens as a dominant domestic terrorist threat. Sovereign citizens believe in an alternate American history with alternative common laws, \emph{posse comitatus}, that extend from historical origins (Berger, 2016). They often learn their ideology from books, videos and internet sources to create more refined, individualized beliefs. Those who are attracted to this subculture typically attend a seminar, or learn from online videos on the subject, and then simply choose how to behave from what they’ve learned. To sovereign citizens, the Fourteenth Amendment shifted Americans from the being citizens of individual states to being citizens of a corporate entity, the federal government. However, they believe that this change in status can occur only if a citizen voluntarily agrees to give up common law rights by seeking licenses or permits, paying taxes, or holding a Social Security number. They believe that a citizen can revoke these licenses and numbers and thus regain common law rights and become a sovereign citizen, and thus become immune to the traditional U.S. judicial system (Berger, 2016; Parker, 2014). They often refuse to pay taxes, refuse to wear masks during the COVID-19 epidemic, and have been involved in violent acts, including killing police officers (Suttmoeller, Gruenewald, Chermak, \& Freilich, 2013) . Their peculiar, rigidly held beliefs can cause court participants to erroneously conclude that they suffer from a mental disorder that renders them incapable of standing trial due to incompetence. However, their beliefs are eventually found to be part of a cultural belief system, and not delusional (Parker, 2014; T. Rahman et al., 2016).]]

\chapter{6. Anti-LGBTQ violence}


Groups that vilify the LGBTQ community have multiplied in recent years. Violence motivated by hatred or bias against gay, lesbian, bisexual, and transgender people is a pervasive problem in American society, (Drake, 2004; Lombardi, Wilchins, Priesing, \& Malouf, 2002) with transgender respondents reporting a high prevalence of transphobic harassment and intimidation, assaults, sexual violence and homicides (Lombardi et al., 2002). In 2017, victims of these hate-based homicides were overwhelmingly transgender women and queer, bi, or gay cisgender men. Moreover, a consistent and steadily rising number of reports of homicides of transgender women of color has been reported (Waters \& Yacka-Bible, 2017). Many anti-LGBTQ groups exist, many of them are religiously motivated. Such extreme overvalued beliefs often demonize sexual minorities, for instance, claiming that “Hitler was gay,” and that the Nazi party was controlled by “militaristic homosexuals” (Schlatter, 2010). After the pulse nightclub attack in Orlando, some religious sermons posted “morally reasoned” dehumanizing labels for LGBTQ people online, such as “sodomites, reprobates, perverts, and scum of the earth” (McPhate, 2016).]]

\chapter{7. Assassins}


Attacks on high-profile politicians with fatal outcomes are rare but have wide ranging socially catastrophic repercussions. John Wilkes Booth infamously yelled “sic semper tyrannis! The South is avenged,” as he leaped onto the stage at Ford’s theater after shooting President Lincoln in the head. Booth, a well-regarded actor, believed Lincoln was “an American Caesar.” The phrase “Sic semper tyrannis” is a Latin phrase that means “thus always to tyrants” and has been used as a “morally reasoned” rallying cry against dictators; some have used it to justify radical views and acts of violence (Iqbal \& Zorn, 2006; Kauffman, 2005). Timothy McVeigh wore a t-shirt bearing this phrase when he attacked the federal building in Oklahoma City on April 19, 1995. Booth held extreme overvalued beliefs of a fanatical nature and he relished and amplified those beliefs. They grew more refined, more resistant to challenge and he acted violently against Lincoln in its service. Other U.S. Presidential assassins have also held rigid, non-delusional beliefs, often while fancying greater aspirations in life.]]


President James Garfield was assassinated by Charles Guiteau just six months into his office on September 19, 1881. Guiteau, was often rejected by young women (they called him “Charles Git-tout’). He later believed that he should be rewarded by the newly elected Garfield administration with a consulship appointment. Since it is customary for canvassing workers to get chosen for such prominent positions, Guiteau reasoned that a political speech he delivered was largely responsible for the election results in Garfield’s favor. After Garfield won, Guiteau eventually moved to Washington D.C. and these beliefs became more dominant and resistant to challenge. He began to badger the newly elected President’s staff and even the President himself for a consulship position. This culminated in his shooting Garfield. At the moment of the assassination, a letter fell from Guiteau’s pocket during the ensuing chaos (Clarke, 1982). The letter, addressed to General Sherman, read:


I have just shot the President. I shot him several times, as I wished him to go as easily as possible. His death was a political necessity. I am a lawyer, theologian, and politician. I am a Stalwart of the Stalwarts. I was with General Grant and the rest of our men in New York during the canvass. I am going to jail. Please order your troops and take possession of the jail at once (p. 209).


At his insanity trial, Guiteau invoked moral religious themes, claiming that he should not be held legally responsible for his acts because it was God’s act and not his. Indeed, just before his execution by hanging, he even believed that he could make a run for presidential office himself in 1884. A jury rejected his insanity plea and he was sentenced to death. He continued to espouse his moral authority and before a noose was placed around his neck, he compared his situation to that of Christ at Calvary (Clarke, 1982). Guiteau’s rigidly held beliefs, along with his moral outrage, were relished, amplified and defended by him to his death. The beliefs that he was special and belonged in President’s Garfield’s office had slowly grown more dominant, refined and resistant to challenge. He had a wishful fantasy to be on the President’s team as opposed to a loss of reality testing that is found in psychosis. He held an intense emotional commitment to his belief and carried out violent behavior against President Garfield in its service.


In Garfield’s case, the assassin fancied serving in the President’s inner circle. Nearly one hundred years later, in the case of President Ronald Reagan, a would-be assassin fixated upon a beautiful blue eyed actress named Jodie Foster. Reagan and others were seriously wounded by John Hinckley, Jr. in an attempted assassination in March 1981. His defense experts argued that Hinckley held delusions stemming from schizophrenia. This contrasted with prosecution claims that he held intense beliefs as part of a personality disorder. It is clear that Hinckley relished, amplified, and defended his affection for the young actress, Jodie Foster in the letters he wrote her. Instead of developing real relationships with women, he became inspired by Foster’s part in the movie \emph{Taxi Driver} in which she played a teenage prostitute. His beliefs that they were destined to be together grew more dominant, refined, and resistant to challenge over time. Despite the knowledge that they could never be together, he held an intense emotional commitment to his overvalued love object, and carried out violent behavior against President Reagan. This is reflected in the testimony of prosecution expert Dr. Park Dietz:


I asked him if he had been trying to impress Jodie Foster, and he said, “Well, it is a combination of things: to impress her, almost to traumatize her. That is the best word. To link myself with her for almost the rest of history, if you want to go that far”\dots{}.I then asked him if he had been trying to communicate something to Jodie Foster, and he said that he had been trying to communicate something to the effect of, “now you will appreciate how much I cared for you. I went to this extent. Now do you appreciate it?” I asked a follow-up to that, which was whether he thought he had accomplished that goal, and he said, “you know actually I accomplished everything I was going for there. Actually I should feel good that I accomplished everything on a grand scale.” I asked him if he really meant that because the statement struck me as an extraordinary one, and he said, “Actually, I accomplished exactly what I wanted to accomplish, without exception.”


(Low, Jeffries, \& Bonnie, 1986, p. 44)


Hinckley relished, amplified, and defended his affection for the actress in the letters he wrote her. The belief grew more dominant, refined, and resistant to challenge over time. He had an intense emotional commitment to her and carried out violent behavior against President Reagan in its service. He held a wishful fantasy as opposed to a loss of reality testing that is found in psychosis (T. Rahman et al., 2019; Meloy, 1989).

\chapter{8. Incels}


Just as anorexics see the world through the lens of “fat” or “skinny” people, Incels see people as “Chads” or “Stacys.” Stacys are described as very attractive yet unattainable, and known for only desiring “Chads.” Chads are men with attractive features such as strong jawlines and defined muscles, who can have sex with lots of women. Women in general are called “femoids” or “FHOs (Female Humanoid Organism).” Members often post images of themselves online and discuss the shape of their skulls, height, face, wrists, etc. These fixations make them think they are unlovable, worthless and that no one will have sex with them, thus rendering them “involuntarily celibate” or “incel”. Their beliefs are refined, becoming more dominant and more resistant to challenge. Some incels carry out violent behavior in the service of these particular extreme overvalued beliefs (Baele, Brace, \& Coan, 2019).


In 2014, Elliot Rodger stabbed his three male roommates to death and went on to shoot three women from outside their sorority before driving through Isla Vista and shooting and ramming several pedestrians from his car. Before going to the sorority, he emailed a 136 page “manifesto” titled “My Twisted World,” to his parents, his life coach, some acquaintances, and several of his mental health providers. In this document, he proclaimed that women have sexually rejected him, even though he is more deserving and entitled to sex than other men. He concluded that humanity is a “disgusting, depraved, and evil species,” and his destiny is to meet divine justice by punishing the men who live better lives than him and the women who gave it to them. The manifesto contains themes of shame, envy, and despair, which he transforms into violence, culminating in his “day of retribution.” Similar to the manifestos seen in the Breivik case, there are portions which taken out of context could be mistaken for delusional content from a psychotic disorder such as schizophrenia. For example, he stated that he has created a “perfect world” in his mind where women are in “concentration camps, starved to death, and then artificially inseminated so that sexuality will completely cease to exist. Love will cease to exist.” When he described his plan for his day of retribution, he wrote “once they see all of their friend’s heads roll onto the street, everyone will fear me as the powerful god I am.” However, when analyzed in the context of the Incel subculture, particularly online, these beliefs can easily be found as shared by others, and not as delusions. Pathological narcissism observed in the Breivik case is also thought to be involved in the Rodger case (the “shy narcissist”) (White, 2017). Extremist ideology, in the way of a religion, can be transmitted easily to others, particularly in online forums. Indeed, in 2018, Alek Minassian drove his van into a busy intersection in Toronto, killing 10 and injuring 13. Minassian identified openly with other Incels and he stated that its culture directly contributed to his own radicalization, and ultimately to violence. He was inspired by Elliot Rodger, whom he referred to as the “supreme gentleman” (Baele et al., 2019). He claimed he had directly communicated with Rodger before his attack, but forensic investigation found no such evidence. At trial the defense psychiatrist argued that a diagnosis of autism spectrum disorder was the cause of his mass murder.


It could be very difficult, if not impossible to identify the beliefs of any radicalized individual without collecting collateral sources of data. This requires an analysis of the person’s culture and subculture as well as character and temperament. Incels on surface appear to be a very different phenomenon from Islamic jihadist or right-wing inspired attacks. However, the behavior clearly has a form consistent with extreme overvalued beliefs, only differing in content. Members of an online subculture such as Incels, Sovereign Citizens, White Supremacists (e.g., Boogaloos, Proud Boys and Atomwaffen), and Islamic Jihadists relish, amplify and defend their respective belief systems, which differ strikingly from their mainstream cultures (T. Rahman, 2018). Therefore, we will next apply the newer DSM-5 cultural formulation and personality models to better describe an individual with extreme overvalued beliefs utilizing validated diagnostic tools.

\chapter{9. Extreme overvalued beliefs and the DSM-5}


Psychiatry has struggled to have reliable and valid tools for threat assessment. Most of the widely used and latest tools are being developed by forensic psychologists (Scott, 2013). The merging of various disciplines is critical to scientific advancement for both forensic psychiatry and psychology. It must be mentioned that legal, clinical and popular culture definitions of a “mental illness” are easily mingled and create confusion for the field. The legal definition of insanity generally requires that an individual suffers from a severe mental illness such as schizophrenia. Personality disorders and substance use have traditionally been excluded by statutes. However, clinical manuals, such as the DSM-5 also contain criteria for disorders that do not meet the legal threshold for insanity (antisocial personality, substance use, pedophilia, etc). The DSM series have largely been controlled by psychiatrists with a strong reliance on a “sign and symptom,” essentially rote-driven approach (P.R. McHugh \& Slavney, 2012).


The definition of extreme overvalued beliefs can be used to formulate a DSM-5 diagnosis. After obtaining a comprehensive history, examination and collateral data, an examiner should determine, as usual, whether the individual suffers from a major mental disorder such as schizophrenia, bipolar disorder, or substance use. If pertinent, a formulation of the individual’s culture, subculture and personality traits should also be made. Since many clinicians are trained to rigorously search for treatable categorical conditions utilizing medications such as psychotic symptoms, mania or depression, they may easily neglect other areas of critical diagnostic importance. They might also find themselves prescribing off –label drugs for mood instability and behavioral problems (Baldwin \& Kosky, 2007; Kharadi, Patel, Rana, \& Patel, 2015), perhaps without even understanding the dispositional and circumstantial provocations of their emotions. Although many clinicians are aware of formalized personality tests, they may not feel qualified to assess such issues (Scott, 2013).


The DSM-5 has now incorporated two new models which may aid in the examination of extreme overvalued beliefs: (1) cultural formulation (Lewis-Ferna´ndez et al., 2014) and (2) alternative model for personality disorders (Morey, Skodol, \& Oldham, 2014) which allow for a more concise approach based on decades of sound scientific premises (Hop- wood \& Sellbom, 2013; Skodol et al., 2011). Although the DSM series were not specifically designed for forensic or threat assessment use, the cultural formulation chapter is useful for a better understanding of the fixation warning behavior used in threat assessment, because it provides a framework for adding the cultural and subcultural “life story” context to a case (T. Rahman et al., 2020). The chapter begins by declaring that “understanding the cultural context of illness experience is essential for effective diagnostic assessment and clinical management.” It goes on to explain that, “\emph{Culture} refers to systems of knowledge concepts, rules and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal customs. Cultures are open dynamic systems that undergo continuous change over time; in the contemporary world most individuals and groups are exposed to multiple cultures which they use to fashion their own identities and make sense of experience. These features of culture make it crucial not to overgeneralize cultural information or stereotype groups in terms of fixed cultural traits.” (APA, 2013, p. 749). The internet has its own culture, and as humans spend more time developing their online social structure, accelerated by the COVID-19 pandemic of 2020, it is crucial to include online use in any forensic or threat assessment (Arshad, Jantan, Hoon, \& Abiodun, 2020). The DSM-5 cultural formulation section concludes that, “Cultural, ethnic and racial identities can be sources of strength and group support that enhance resilience, but they may also lead to psychological, interpersonal, and intergenerational conflict or difficulties in adaptation that require diagnostic assessment” (p. 749). Difficulties in adaptation are frequently seen in the pathological preoccupation with a person or cause in fixations due to extreme overvalued beliefs; these can lead to the development of other warning behaviors such as thwarting of occupational goals, changes in thinking and emotion, and identification as an agent to advance a particular cause or belief system (J.R. Meloy, 2017).


It must be clarified that the terms \emph{culture} and \emph{subculture} are important to tease apart. For example, a person that opposes abortion rights might be very different from individuals that believe killing an abortion performing doctor is a morally justified act. Osama bin Laden, without any formal religious authority, inspired his followers to carry out the 9\Slash{}11 attacks, orchestrated with others that shared his ideology of liberating Islamic holy land from American influence, with the reward of heaven awaiting those that perished in its service. The ideology of al-Qaeda (binLadenism) is a deviant strain of mainstream Islam, but like antiabortionist or other religious, political, and other “morally driven” movements, can become latched on to by others who are vulnerable to fixation driven by extreme overvalued beliefs. Al-Qaeda, like white supremacy groups (e.g. Boogaloo Bois, Rise Above Movement, Atomwaffen, Proud Boys) contain within them a \emph{subculture} and can vary significantly from the more moderate mainstream racism, antiSemitism, or anti-government beliefs that are pernicious undercurrents in the culture. Many individuals fantasize about committing crimes to profit financially, emotionally, sexually, and socially. Indeed, popular culture glorifies these behaviors to millions of voyeuristic audiences eager to watch or read about massacres, bombings, sexual fantasies, homicides, suicides and assassinations. However, some individuals, similar to anorexics and dieting, develop pathological fixations on these topics (T. Rahman, 2018). The fixations require a deeper understanding of the individual’s character and temperament, within the context of his or her culture and subculture. These may also contain psychoanalytic nuggets which are unique to each individual and requires a deeper person-centered probing (Weiss, 2016).


A complex link between the person, their situation and future response requires an analysis of not just biological laws, but understanding people and their emotional difficulties (P.R. McHugh \& Slav- ney, 1998). As the Breivik, Sovereign citizen, violent jihadist, extreme right wing and Incel cases highlight, personality traits and subcultural beliefs are of critical importance in lone actor terrorism cases, and can easily distort the observed diagnostic assessment (J.R. Meloy \& Rahman, 2020; T. Rahman et al., 2019). Terrorists for the most part do not have serious psychopathology as seen in DSM-5 “disease category” disorders such as schizophrenia (Goertzel, 2002). Instead, we propose that correlates from database studies should be applied to DSM-5 character and temperamental traits (using the newer dimensional models of personality). For instance, several reliable and valid correlates of lone actor violence have identified aspects that are pertinent to the DSM-5 sections we have discussed above. Of critical importance, \emph{fixation} (due to extreme overvalued beliefs) on a subject or person as a substitute for a real relationship requires an assessment of a person’s cultural background and identification of any pathological personality traits. Ideological framing, moral outrage, pathological narcissism, and failure to form an intimate sexual pair bond, as well as changing in thinking and emotions (all correlates of lone actor violence) can easily be discovered through information gathered with structured interviews and collateral information relying on cultural formulation and assessment of personality traits, rather than only reliance on cardinal signs and symptoms of serious mental disorders (J.R. Meloy, 2017; T. Rahman et al., 2019; T. Rahman et al., 2020).


On the surface, the categorical system of the DSM-5 may not appear to allow for dispositional and provoking events to describe an act of violence based on extreme overvalued beliefs. However, we have tried to show how the concept of extreme overvalued belief alerts the examiner to further probe an individual’s biographical or life story elements. The DSM-5 has aimed to address numerous shortcomings of the current categorical approaches to disorders, and has clarified the fact that “the typical patient meeting criteria for a personality disorder frequently also meets criteria for another personality disorder.” (APA, 2013, p. 765). This alternative model now has Criterion A-F which includes A) Levels of personality functioning, B) Pathological personality traits C–D) Pervasiveness and stability and \emph{E}-F) Alternative Explanations for personality pathology. The model includes two important domains 1) self and 2) interpersonal. Self includes identity and selfdirectedness and interpersonal includes empathy and intimacy. Although a person may not always meet the threshold for needing psychiatric medications, psychiatric hospitalization, or meeting the strict legal criteria for insanity, it is critical to include the above mentioned sections of the DSM-5 for a proper diagnostic assessment in forensic cases. The examiner can then move away from signs and symptoms (e.g. mania or psychosis) and into the domains of emotions, life events, traits, and temperament (APA, 2013; P.R. McHugh \& Slav- ney, 1998). Perhaps most importantly, they help us formulate a case such as Anders Breivik, Osama bin Laden, Ted Kaczynski (Unabomber) or Malik Nidal Hassan (Fort Hood shooter) where there is no clear mental disorder to describe (J.R. Meloy \& Rahman, 2020; T. Rahman et al., 2019).

\chapter{10. Conclusion}


The articles in this special issue highlight the important cognitive driver of \emph{extreme overvalued beliefs} as the motive for various types of targeted violence. It is critical to understand an individual’s biographical narrative, personality traits and the backdrop of his or her culture and\Slash{}or subculture (including online) formulation to uncover shared beliefs or ideologies that might differ from mainstream ideologies in an otherwise normally appearing individual. This poses a challenging problem because mainstream cultural examiners and experts might not truly understand the complexities of a subcultural group’s beliefs, rituals, customs, and online presence. A failure to carefully and appropriately identify these subcultural traits can distort the diagnostic assessment. The DSM-5 cultural formulation and alternative personality models can be used to develop a person-centered process to facilitate a practical diagnostic assessment. It is of critical importance that forensic examiners pay close attention to the proper definitions of delusion, obsession and extreme overvalued beliefs and how they can differentially drive a pathological fixation: a preoccupation on a person or a cause that is accompanied by a deterioration in social and occupational life (Hoffmann et al., 2011). It is through this process that we can have a more coherent discussion about whether or not acts of targeted violence are caused by a mental illness and how to prevent them.

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The Ted K Archive





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Tahir Rahman, Lingjin Zheng, J. Reid Meloy

DSM-5 cultural and personality assessment of extreme overvalued beliefs



7 January 2021


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Aggression and Violent Behavior Volume 60 - \href{https://www.elsevier.com/locate/aggviobeh}{www.elsevier.com}
   

       

       

       

       

       

       

   



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\textbf{www.thetedkarchive.com}


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