Stockholm Syndrome': Psychiatric Diagnosis Or Urban Myth?

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'Stockholm syndrome': Psychiatric diagnosis or urban myth?

Article in Acta Psychiatrica Scandinavica · February 2008 DOI: 10.1111/j.1600-0447.2007.01112.x · Source: PubMed

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Nicola Tufton Elizabeth L Sampson Queen Mary, University of London University College London

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Review ÔStockholm syndromeÕ: psychiatric diagnosis or urban myth?

Namnyak M, Tufton N, Szekely R, Toal M, Worboys S, Sampson EL. M. Namnyak, N. Tufton, R. Szekely, ÔStockholm syndromeÕ: psychiatric diagnosis or urban myth? M. Toal, S. Worboys, E. L. Sampson Objective: ÔStockholm syndromeÕ is a term used to describe the positive Department of Psychiatry and Behavioural Sciences, bond some kidnap victims develop with their captor. High-profile cases Hampstead Campus, Royal Free and University College are reported by the media although the diagnosis is not described in Medical School, London, UK any international classification system. Here we review the evidence base on ÔStockholm syndromeÕ. Method: Databases (PubMED, EMBASE, PsycINFO, CINAHL) were systematically searched. We compared features of cases widely reported in the English language media to identify common themes which may form a recognizable syndrome. Key words: ÔStockholm syndromeÕ; review, systematic; Results: We identified 12 papers that met inclusion criteria. The hostage; mass media existing literature consists mostly of case reports; furthermore there is Elizabeth L Sampson, Department of Psychiatry and ambiguity in the use of the term. No validated diagnostic criteria have Behavioural Sciences, Hampstead Campus, Royal Free been described. Four common features were found between the five and University College Medical School, Rowland Hill cases studied. Street, London, NW3 2PF, UK. Conclusion: There is little published academic research on ÔStockholm E-mail: [email protected] syndromeÕ although study of media reports reveals similarities between well publicized cases. This may be due to reporting and publication bias. Accepted for publication September 21, 2007

Summations • ÔStockholm syndromeÕ is commonly used by media sources as a term to describe the positive bond a kidnap victim develops towards their captor. • No validated diagnostic criteria for ÔStockholm syndromeÕ have been described; existing literature is of limited research value and does little to support ÔStockholm syndromeÕ as a psychiatric diagnosis. • Analysis of cases widely reported in the media reveals four common features in victims of ÔStockholm syndromeÕ; each victim experienced direct threats, they were kept in isolation, had an opportunity to ÔescapeÕ during their period of captivity but failed to use it and showed sympathy with their captors postcaptivity. This suggests an identiﬁable pattern of experience and behaviour may exist amongst victims described by the media.

Considerations • ÔStockholm syndromeÕ is not a recognized Medical Subject Heading (MeSH). • Sources of information for widely publicized cases were of varying reliability in terms of the events that lead to the diagnosis of ÔStockholm syndromeÕ; the authors had no access to primary sources. • Identiﬁcation of a pattern of features exhibited in ÔStockholm syndromeÕ may be due to reporting bias.

emotional bond a kidnap victim may develop Introduction towards their captor. It is speculated that this bond The term ÔStockholm syndromeÕ, eponymously develops as part of the victimÕs defence mechanism named after a failed bank robbery in Stockholm, to allow them to sympathize with their captor, Sweden, has been used to describe the positive leading to an acceptance of the situation, limiting

1 Namnyak et al. defiance ⁄ aggression toward the captor and thus and describe any existing diagnostic criteria. We maintaining survival in an otherwise potentially will compare and contrast the features of high- high-risk scenario (1). The terms Ôterror bondingÕ profile cases of victims of ÔStockholm syndromeÕ to and Ôtraumatic bondingÕ have been used as syn- identify common features between each case. We onyms to ÔStockholm syndromeÕ (2). will evaluate the current evidence regarding ÔStock- On the morning of Thursday 23 August 1973, a holm syndromeÕ; is it a valid psychiatric construct, 32-year-old prison-escapee, Janne Olsson, armed or merely a convenient label adopted by the media with a submachine gun, walked into the Sveriges for high-profile cases? Kreditbanken in Norrmalmstorg Square, Stock- holm, Sweden. He fired several rounds from his weapon, injuring one police officer. He then took Material and methods four bank clerks hostage. OlssonÕs first demand Systematic review was that his prison-mate, 26-year-old Clark Olo- fsson, should be released from prison and allowed We developed a broad search strategy as we were to join him; the Swedish government agreed to the aware that little work in this field had been demand. Olofsson joined Olsson and the pair published and we wished to include as many proceeded to barricade themselves and their four papers as possible for final review. An initial hostages into the bankÕs 3.3 · 14.3 m vault (3). search strategy was developed for the PubMED The ensuing chain of events would lead to what is database by searching the text term ÔStockholm now known as ÔStockholm syndromeÕ. The four syndromeÕ (it is of note that it has not been hostages appeared to bond with the captors: they allocated a MeSH). We searched for ÔStockholm seemingly did not want to be rescued by the police. syndromeÕ and then searched for the following text One is quoted as saying ÔThis is our world now … terms: Ôterror bondÕ, Ôtraumatic bondÕ, Ôkidnap sleeping in this vault to survive. Whoever threatens victimÕÔhostageÕ (MeSH term) and the names of this world is our enemyÕ (4). high-profile kidnap victims. The name ÔNils Bej- To date, there have been few studies on the erotÕ was also searched as he was the psychiatrist frequency of ÔStockholm syndromeÕ amongst involved in hostage negotiations at the original kidnap victims or its long-term effects on their Stockholm bank robbery and coined the phrase mental health. Furthermore, although different ÔStockholm syndromeÕ. All search terms were then ratings scales exist for identifying ÔStockholm combined with ÔStockholm syndromeÕ using the syndromeÕ in women who have experienced domes- ÔANDÕ Boolean and were translated and repeated in tic abuse (2) and in soldiers involved in combat a range of databases. Those searched up until 31 (where it is described as Ôacute operational stressÕ) January 2007 were EMBASE (Excerpta Medica (5), ÔStockholm syndromeÕ is not included in any Database 1980+), PsycINFO (1876+), CINAHL international classification system of psychiatry. In (Cumulative Index to Nursing and Allied Health ICD-10 the category ÔAcute stress reactionÕ 1982+), PubMED, SIGLE, Google Scholar, ISI (F43.0), includes Ôtransient disorders triggered by Web of Knowledge and The Cochrane Library. exceptionally stressful life eventsÕ, is probably the Reference lists in retrieved papers and reviews of most relevant (6). the subject were hand searched. Criteria have been proposed to describe ÔStock- Papers were selected using the following criteria: holm syndromeÕ; the most widely quoted are articles had to include the term ÔStockholm syn- GrahamÕs (1995) criteria based on a study of nine dromeÕ and be published in the English or Swedish different victimized groups (2) Graham postulates language. If there was disagreement as to the four precursors to the development of ÔStockholm inclusion of a publication, the paper was reviewed syndromeÕ: i) that there exists a perceived threat to by an independent reviewer (ELS). All findings survival and belief that the threat will be carried were tabulated (Table 1). out, ii) that the captiveÕs perceive some small kindness from the captor in the context of terror, Analysis of cases reported by the media iii) that the hostage experiences isolation from perspectives other than those of the captor and iv) These cases were identified using common internet that the hostage has a perceived inability to escape. search engines (i.e. Google) and media databases including LIBRIS (the National Library of Swe- denÕs online bibliographic service) using the search Aims of the study term ÔStockholm syndromeÕ. A detailed narrative To systematically review the existing published on each case was prepared by individual authors literature on ÔStockholm syndromeÕ and identify using British and USA media archives (Times

2 Stockholm syndrome

Table 1. Summary of published literature on ÔStockholm syndromeÕ

Author Methodology No. of subjects Main findings

Favaro et al. (1) Retrospective, semi-structured 24 ÔStockholm syndromeÕ is an indicator of severity of the experience, interview linked to isolation and dehumanization. No correlation with development of PTSD Auerbach et al. (8) Captivity simulation with 57 Emotion-focused training created more friendly hostage behaviour structured interviews which tends to evoke a friendly dominant behaviour from the terrorist. Emotion-focused training enhanced hostages ability to adjust to stress of captivity Julich (10) Retrospective unstructured 21 Children are particularly susceptible to developing ÔStockholm interviews syndromeÕ. Childhood sexual abuse may not be reported due to bond of ÔStockholm syndromeÕ Graham et al.(2) Questionnaire 764 Cohort of women interviewed on a university campus about their current and past relationships Strong states of arousal, caused by fear, may be misinterpreted as attraction (bonding). By labelling feelings as love, it provides hope and therefore possible routes of escape. Length of time in relationship, both before and after abuse started, relates to likelihood of development of ÔStockholm syndromeÕ. ÔStockholm syndromeÕ may relate more to psychological then physical violence Wesselius and DeSarno (9) Structured interviews 6 Only one out of six hostages developed ÔStockholm syndromeÕ. This hostage had most positive contact with hostage taker Naber-Morris (12) Validation of a questionnaire 563 Theorized precursors to the development of ÔStockholm syndromeÕ based upon female students that were child victims of abuse, completing questionnaires as: i) threat to oneÕs life; ii) inability to escape from abuser; iii) isolation from others; iv) victimÕs perception of some kindness by abuser Solomon (7) Interviews 35 Levels of ÔStockholm syndromeÕ increase with better quality of treatment by captors. Abuse by captors discourages the development of ÔStockholm syndromeÕ Fulton (14) AuthorÕs opinion NA Reflective essay on the development of emotional ties between care workers and clients in residential homes. Mainly based on personal experiences West (11) Review of case studies and NA Pseudo-identity is a response to stress, and enables victims to cope with review articles extraordinary situations Gordon (32) Academic internet review NA The process of identification with the terroristÕs view-point has manifested itself in the reactions of the US with increasing interest in the study of terrorism Cassidy (33) Case ÔscenariosÕ NA Psychological exploration of ÔscenariosÕ about cult members, domestic violence victims and women in abusive relationships Slatkin (34) Case reviews 20 000 FAA, FBI and police prison records of 447 hijackers and their hostages involved in skyjackings. Factors of length of captivity and quantity of interaction had a positive relationship with the development ÔStockholm syndromeÕ

online, Chicago Tribune and CNN), as well as CINAHL (10). When the search term ÔhostageÕ was newspaper articles and transcripts from interviews searched, PubMED produced 221 results; however with the victims and their families after the event. when the ÔANDÕ Boolean was used to include Results were then tabulated according to a frame- ÔStockholm syndromeÕ only three articles were work of themes; Ôduration of captivityÕ, Ôexperi- retrieved. Similarly, when the term ÔKidnap ences during captivityÕ, ÔhostageÕs postcaptivity victimÕ was searched on the same database, 2945 experiencesÕ. These themes were used to compare results were found, yet using the ÔANDÕ Boolean to and contrast the circumstances surrounding each include ÔStockholm syndromeÕ yielded four results. of the kidnaps and the situations in which the These ﬁndings demonstrate how although research victims were held in. into hostage situations does occur, the term ÔStockholm syndromeÕ is rarely used or recognized in academic research. Results A total of 12 papers met the inclusion criteria and are described in Table 1. The available Systematic review literature centres mostly on case reports based Of the eight databases that were searched, only upon retrospective interviews with hostages, three yielded results for ÔStockholm syndromeÕ, people who have experienced child abuse and these were PubMED (11), PsychINFO (44) and victims of domestic violence. Many of the

3 Namnyak et al.

findings in these papers were contradictory. One feel toward their client as ÔStockholm syndromeÕ states that ÔStockholm syndromeÕ is an indicator (14) to describing the relationship between victims of severity of the experience (1), while another of child sexual abuse or domestic violence and their study concludes that the ÔlevelÕ of ÔStockholm abuser (2, 10). syndromeÕ that a hostage experiences increases with better quality of treatment by the hostage Analysis of high-profile reported cases taker and that in fact abuse by the captors discourages the development of ÔStockholm syn- The five selected cases were widely reported in the dromeÕ (7). Another study suggests that the media. Table 2 outlines the main events that development of the syndrome may be related occurred in the individual cases. The largest more to psychological abuse rather than physical source of information for these cases was from abuse (2). In a study that attempted to simulate non-peer-reviewed media in the form of internet the experience of captivity the authors found that archive material, newspaper articles and interview when the ÔhostagesÕ had previous emotion-focused transcripts. Since the 1970s, the label ÔStockholm training to create a more friendly behaviour on syndromeÕ has been used to describe the behaviour the part of the hostage this evoked a friendly, of a number of kidnap victims, who have appar- dominant behaviour on the part of the hostage ently behaved in similar ways to as the original taker (8), possibly increasing the likelihood of a Stockholm hostages. In 1974, American heiress, positive bond to develop. Similarly, using struc- PH, was abducted by the Symbionese Liberation tured interviews, Wesselius and DeSarno (9) Army. For the first 57 days of her captivity she was found that only one of the six hostages inter- locked in a closet and subjected to physical and viewed had developed ÔStockholm syndromeÕ; this sexual abuse, following which she remained loyal hostage had experienced the most positive contact to her captors and even assisted them in terrorist with the captor. activity. In her trial she claimed she had been Very few of the studies attempted to explain why brainwashed and intimidated and coerced into her ÔStockholm syndromeÕ may develop in victims, but part in the robbery (15). several theories were put forward. Young people More recently in 2003, ES was returned home may be particularly susceptible to developing following 9 months of captivity at the hands of ÔStockholm syndromeÕ as they develop positive Wanda Ileen Barzee and Brian David Mitchell. feelings toward the adults to whom they are Mitchell purportedly took ES to be his wife dependent on for protection and provision of following a religious revelation (16). During her basic needs. This makes them less able to relinquish captivity ES was physically and psychologically this positive bond if the adult becomes the abuser abused; tied to a tree, kept in a hole and threatened (10). In a hostage scenario, the victim becomes the with a knife. She was taken out in public, but made child and the hostage taker the adult. to wear heavy veils and prohibited from speaking Several authors postulate that hope of escape to anyone. Despite this she had opportunities to may be an underlying cause. Strong states of escape which she never utilized (17). Upon her safe arousal, caused by fear, may be misinterpreted as return there was much frustration in the commu- attraction (bonding); by labelling these feelings as nity when it was discovered that she had gone love, it provides the hostage with hope and unrecognized among them and not sought help (16, therefore possible routes of escape (2). By adopting 18). a friendlier behaviour, the hostage may adapt Over the past year, two other kidnap cases have better to the stress of captivity (8). Taking on a been widely reported in the media: NK and SH. pseudo-identity is also thought to enable victims to NK, aged 10, was abducted while on her way to cope better with captivity (11) as it may create a school in Vienna in 1998 by Wolfgang Priklopil. psychological separation between their normal Thereafter she was held for 8 years, initially in a world and their captive state (see Table 1 for a small windowless room, where she was beaten and summary of the existing literature). photographed by her captor. In later years she had We did not identify any validated diagnostic a number of opportunities to escape. She escaped criteria for ÔStockholm syndromeÕ in any of the in 2006, when Priklopil was distracted; she has papers reviewed in this study, although a few since expressed signs of grief over PriklopilÕs papers offer suggestions for potential criteria subsequent suicide (19–23). SH was allegedly (2, 12, 13). A large discrepancy regarding the kidnapped in 2003 at the age of 11. He was definition of ÔStockholm syndromeÕ exists between found in 2007 following a police investigation into the papers reviewed. The definition ranged from the abduction of another young boy. Since his labelling the bond a residential care worker may release, it has become apparent that he lived with a

4 Stockholm syndrome

Table 2. Analysis of high-profile media cases

Name (initials) (age), location and length Pseudo-identity of captivity Perpetrator and motive assumed Experiences during captivity Postcaptivity experiences

EO (20 years), KE Jan Erik Olsson was on leave None Hostages were threatened with death None of the captives have (23 years), BL from prison when he walked if ransom demands were not met; publicly denounced the (30 years), SS into the a bank in Stockholm, perpetrators carried guns at all behaviour of their captors. (24 years) opened fire on two policemen times and used them to threaten Reports exit that the four Randomly taken and took four hostages. He the captives captives refused to testify hostage at a demanded that his friend Clark Captives were forced into snare traps at the trial and even raised bank robbery Olofson be allowed to join him around their necks, so that in the money for their kidnappersÕ Stockholm, and a ransom to the equivalent event of a police intervention with legal fee. Sweden of $730 000 in return for the gas the hostages would strangle At least one of the captives is 6 days hostages safety themselves known to have remained in When hostages were confronted by contact with their captor. police during the stand-off, they The psychiatrist Nils Bejerot made hostile comments toward the used the term ÔStockholm police. There are reports of hostages syndromeÕ to describe the resisting being rescued by police captivesÕ behaviour ES (14 years) Brain David Mitchell (50-year-old) Yes – Threatened with a knife and tied to a Identified herself as ÔAugustineÕ Salt Lake City, and Wanda Ileen Barzee. Mitchell ÔAugustineÕ tree or kept in a hole. Reportedly also and said ÔI know what youÕre USA believed he was a Mormon prophet experienced rape, verbal abuse and the thinking. You guys think that 9 months and took ES to be his ÔwifeÕ threat of violence during captivity. Taken IÕm that … girl who ran awayÕ. into public spaces at times, but was She repeatedly asked what forced to wear heavy veils and was not would happen to her captors, allowed to speak to anyone but captors. showing ongoing concern for Had opportunities to escape or be their welfare. Mitchell was rescued but did not utilize them declared mentally incompetent to testify at the trial NK (10 years) Wolfgang Priklopil abducted NK on Kept in a small room with no windows. Felt she had not missed anything Vienna, her way to school. The media After 6 months allowed upstairs during during her imprisonment. Her Austria speculated that his motives for the day. Threatened with the idea that if captor committed suicide this were for child. However, NKÕs she tried to escape she would be blown shortly after her escape. She account after kidnapping does not up. She was beaten and photographed by expressed sadness and grief explicitly validate these theories Priklopil. Had several opportunities to over this. Reported that in some escape – even went on a ski-trip with ways her captivity was a good her captor thing as it meant she wasnÕt exposed to negative influences. States that she knew she didnÕt want to remain in captivity as it wasnÕt the purpose of her life and felt it was unfair SH (11 years) Michael Devlin allegedly abducted Yes – took There were many opportunities for escape SH has kept his opinions to Missouri, SH while he was riding his bicycle perpetratorÕs during captivity. He is reported to have himself thus far and communicated USA in woods near his home surname conducted a relationship with a local girl primarily through his mother. 4.5 years close to his alleged captorÕs home. Had At this point in time, the trial personal contact with police on two of Devlin is yet to begin separate occasions, where he identified himself as alleged captorÕs son PH (19 years) Symbionese Liberation Army (SLA), an Yes – ÔTanyaÕ Kept blindfolded in a closet for 57 days. In her trial, PH claimed she had Berkeley, USA American paramilitary ⁄ terrorist group and ÔPearlÕ Physically and sexually abused and forced been abused, which caused her 19 months active in the 1970s. Intended to swap to confess past misdeeds, which were to join the SLA. Defence was PH for jailed members of the SLA. manipulated so that PH became critical of based around the claim that her This failed and so they demanded herself and her familyÕs wealth. She joined actions could be attributed to ransom of $6 million worth of food the SLA in their criminal activities and was being brainwashed. PH argued for the bay area of San Francisco, famously caught on film wielding an she was coerced and intimidated USA. PH was still not released assault rifle while robbing a bank in into her part in the robbery; she San Francisco. During the robbery, PH was convicted and sentenced to had several opportunities to escape 7 years which was annulled by President Carter. She served only 22 months. After her release from prison, PH married her former bodyguard. She has written several books and has had roles in several films. Granted a full pardon by President Clinton in 2001

5 Namnyak et al. significant degree of freedom, even having a A ÔsyndromeÕ is defined as Ôa combination of relationship with a local girl. He too never utilized signs and ⁄ or symptoms that form a distinct clinical his freedom to escape (24–28). picture indicative of a particular disorderÕ (29). The Many similarities between each case were iden- data drawn from the five cases studied identify a tified. All the victims of ÔStockholm syndromeÕ had pattern of similar experiences between each case been abducted or held hostage by persons previ- (Table 2). However whether these similar experi- ously unknown to them and were held in close ences are characteristic of a specific abnormality confines, isolated from the outside world and (i.e. ÔStockholm syndromeÕ) or whether they char- subjected to only the captiveÕs perspective. All acterize the behaviour one experiences under victims experienced abuse, although the extent and extremely stressful situations, such as a being type of abuse (physical, sexual, emotional or taken hostage, must be accurately assessed. Our neglect) that occurred during the time of captivity research into the five high-profile cases revealed is unclear in some of the cases. They all experienced four common features: each victim experienced a continuing threat to their survival during their direct threats of physical ⁄ sexual abuse ⁄ emotional time in captivity and many of the victims assumed abuse made against them; they were all kept in pseudo-identities. isolation in close confines and ⁄ or physically All victims had opportunities to escape (with the restrained; they all had an opportunity to ÔescapeÕ exception of the hostages in the Norrmalmstorg during their period of captivity but failed to use it, bank robbery), which they did not utilize; in all with the exception of the Norrmalmstorg robbery cases after their rescue and safe return, victims (it can be argued that the hostages in Norrmalm- showed sympathy towards their captors. There storg may not have voluntarily left the situation) were also several demographic similarities between and they all showed sympathy with their captors the victims. All were relatively young at the time of postcaptivity. These common features identified in their captivity (range: 10–30 years). the high-profile cases are similar to previous research theorizing the precursors for the development of ÔStockholm syndromeÕ (2, 12). Discussion The five ÔStockholm syndromeÕ cases in this The existing literature on the subject of ÔStockholm study captured the publicÕs attention via high- syndromeÕ is sparse; the majority of the literature is volume media coverage both during captivity and based on case reports with little reference to how immediately after release. It may be that the label ÔStockholm syndromeÕ was diagnosed and what, if of ÔStockholm syndromeÕ helps to negate the need any, is its significance in terms of management of to explain inexplicable behaviour. We find little victims. ÔStockholm syndromeÕ is rarely mentioned evidence that it describes a specific psychiatric in peer-reviewed academic research. syndrome that may require specific treatment or In some studies, adapted existing scales for have long-term implications for the mental health depression and post-traumatic stress disorder of its victims, indeed, one study reported that the (PTSD) were used (2, 8, 12). Several criteria have development of ÔStockholm syndromeÕ was actually been suggested to describe ÔStockholm syndromeÕ; unrelated to the development of PTSD (1). the most widely quoted is GrahamÕs (1994) criteria Our analysis of reported cases suggests that the based on a study of nine different victimized impact of captivity may have a lasting impact on groups (2, 12) although this is not a set of personality and function. The captives described in validated diagnostic criteria. This lack of stan- case reports are all young; it is most likely that the dardization has created ambiguity with regards to impact of captivity earlier in life has a profound what a diagnosis of ÔStockholm syndromeÕ actually effect on future personality development and means and bias within studies leading some to functioning. It is interesting to contrast this with conclude that ÔStockholm syndromeÕ is a rare the experience of older captive hostages (for occurrence, while others suggest it is a more example, in the 1980s several people were taken common phenomenon. Furthermore, this review hostage in Beirut, Lebanon. These included Brian was unable to identify any studies that validate Keenan, a 35-year-old held for over 4 years (30) ÔStockholm syndromeÕ as a separate nosological and Terry Waite, a hostage negotiator, held for entity, leaving us to question the use of the term: is 5 years, at the age of 48 (31). They did not develop it purely a fabrication of the media to allow society such a bond with their captors. to assimilate the behaviour of captor and captive The major limitation for this study is reporting into a manageable entity or does it have a bias. We relied upon information from media distinctive phenomenology suggestive of a valid sources for accounts of the five cases. The fact that psychiatric syndrome? the concept of ÔStockholm syndromeÕ has been

6 Stockholm syndrome broadened to describe a variety of situations also factor structure, reliability and validity. Violence Vict acted as a limitation, blurring the original meaning 1995;10:3–22. Pilevsky P of the term which was to specifically describe the 3. . Chapter 2: The ÔStockholm syndromeÕ captive continent: the ÔStockholm syndromeÕ in European–Soviet positive bond between hostage and captor. In relations. Westport, CT: Praeger Publishers, 1989. addition we found that most of the ÔdiagnosesÕ of 4. Norrmalmstorgsdramat-sÕ lever gisslan I dag, 2003. ÔStockholm syndromeÕ have been made by the Available at: http://www.expressen.se/1.43622 (accessed on media – we had no access to primary sources of 15 December 2006). 5. Pearn J. Traumatic stress disorders: a classification with information such as mental health assessments. If implications for prevention and management. 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