On 22 July 2011, Anders Behring Breivik carried out the worst attacks in Norwegian history since the Second World War, killing 77 men, women and children and injuring another 151 people. In November 2011 he was declared to have paranoid schizophrenia by a court-appointed panel of forensic psychiatrists. ¹ Breivik's diagnosis evokes memories of Nicky Reilly, who has Asperger syndrome and was convicted of trying to blow up a shopping centre in Exeter in May 2008, and Andrew Ibrahim, a former drug addict who was jailed for making a bomb at his flat in Bristol in April 2008. ^{Reference Dyer2}

The notion that most forms of terrorism are an understandable (if not condonable) reaction to limitations on freedom and equality has lost ground in many countries. As psychiatrist Gerrold Post pointed out, ‘there is a broad spectrum of terrorist groups and organizations, each of which has a different psychology, motivation and decision making structure. Indeed, one should not speak of terrorist psychology in the singular, but rather of terrorist psychologies’. ^{Reference Post3} Terrorist violence most often is deliberate (not impulsive), strategic and instrumental; it is linked to and justified by ideological, for example political or religious, objectives. In Breivik's case, his stated objective was to ‘defend Europe against a Muslim invasion’, ¹ which is now being considered as part of a well-formed delusional belief system. These issues all add complexity to the construction of terrorism as a form of violence and stretch the limits of present-day clinical risk assessment.

In recent guidance, the UK Home Office requested an increased role from the UK medical professionals in identifying people at risk of committing future terrorist acts. ⁴ This raises a number of ethical and professional considerations which are particularly relevant to psychiatrists, given an almost certain role which might be expected from the profession in not only identifying, but treating and risk-managing terror suspects. The following four questions are pertinent in this regard.

1. 1. Would an enhanced role in identifying and referring terror suspects as suggested by the Home Office leave the profession losing patients’ trust in psychiatrists’ professionalism and patients’ confidentiality, as suggested by some? ^{Reference English5}

2. 2. How would the public protection be balanced with the individual patient freedom in an environment of ever-increasing public protection and aversion to risk?

3. 3. Even if psychiatrists agree to move to the forefront in the war against terror, how would our currently relatively unsophisticated arsenal of risk assessment tools detect and quantify such a complex, low-frequency and constantly changing threat?

4. 4. The elusive question, ‘Is terrorism a mental disorder?’ remains unanswered and many would continue to challenge the psychiatrists’ role in identifying, and potentially managing, terrorist suspects.

In our view, with the terrorist threat remaining as one of the major public protection issues for the foreseeable future, these questions will become more pertinent. The profession should without delay embark on an open and honest discussion on its role in this crucial public protection issue, and develop a clear view.