"Mr. S, a middle-aged Caucasian man, was born in the Pacific Northwest to married parents and was the middle of three children. His mother had a history of depression, and his father was an alcoholic. He described his family as being “dysfunctional,” with little, if any, emotional support from an overly intrusive mother, disciplinarian father, and two siblings. Mr. S met his childhood developmental milestones and had no reported history of intellectual or learning disabilities. He described having anxiety growing up, mainly in social situations. He denied childhood sexual abuse, but he did describe corporal punishment from his father. Mr. S had a history of alcohol abuse starting in his mid-twenties and continuing into his early forties. He denied any significant medical history. He denied legal difficulties, psychiatric hospitalizations, and suicide attempts. He was single, had never been married, had no children, and reported having only one close friend for most of his life. He never had a close long-term romantic relationship and stated a clear preference for living a solitary life. After completing high school, Mr. S joined the military and served in various non-combat occupational roles. He enlisted twice in the military and was honorably discharge after each duty. Although he served overseas for a period of time, he did not serve in a combat zone or experience physical or psychological trauma. He did not sustain any known injuries while in the military and he was never diagnosed with, or filled for, a service-connected disability. After discharge from the military, he supported himself by working as a facilities security guard, always taking the night shift given his preference for working alone and avoiding people. While living in the Pacific Northwest, he lived out of his van, which he parked outside of his mother's house. After the death of his father, he assumed the role of primary caretaker for his mother. Mr. S reported that his mother was “frail” and “elderly” but did not report that she was on disability. He reported significant resentment toward his siblings for not participating in their mother's care, prior to his mother moving into a nursing home. Several months after his mother moved into a nursing home, Mr. S relocated out of the Pacific Northwest, found a new facilities security job, moved into a new residence, and no longer lived out of his van.
One year prior to his admission to the psychiatric hospital, Mr. S sought outpatient therapy for depression and engaged in weekly supportive psychotherapy with a young female psychology intern. His psychiatrist started an SSRI antidepressant and a low dose of antipsychotic medication for “depression with psychotic features.” Mr. S's alleged psychosis consisted of “voices” of crowds of people saying things that he could not make out, which he experienced while working the night shift. He consistently attended his therapy sessions and was noted to be making progress. However, several months into his therapy, Mr. S told his therapist that he had been involved in of military combat and described himself as a decorated war hero. After several therapy sessions in which he recounted his combat experiences, Mr. S was queried as to whether he ever killed anyone, to which Mr. S replied, “During the military or after the military?” He then told his therapist that he had followed, raped, and killed numerous women during the 20 years since leaving the military.
Mr. S reported that he would follow a potential female victim for several months before raping and strangling her to death with a rope. Although he claimed to rape and kill the women, he did not describe any sexual arousal from the subjugation, torture, or killing of his alleged victims. He refused to disclose how many women he had killed, where he had killed them, or how he had disposed of their bodies. He described having purchased various supplies to aid in abduction, which he kept in the back of his van while cruising for victims. These supplies included rope and two identical sets of clothes and shoes to help evade detection by the police. He described using various techniques to track his victims, as well as evade surveillance of his activities. He informed his therapist that he was actively following a woman he had encountered in a local public library several days earlier. Mr. S acknowledged that he studied the modus operandi of famous sexually sadistic serial killers by reading books. The patient's therapist, feeling frightened and threatened by these disclosures, transferred his case to her supervisor, who then saw the patient for a few therapy sessions. Mr. S reported worsening depression, hearing more “voices,” and attempting to self-amputate his leg using a tourniquet. Consequently, Mr. S was involuntarily detained as a “danger to self” and “danger to others” for evaluation in the local psychiatric hospital.
Mr. S's admission physical and neurological examinations, routine laboratory results, and urine toxicology screen were unremarkable. His outpatient medications were continued for a provisional diagnosis of major depressive disorder, single episode, unspecified severity, with psychotic features. Mr. S refused to provide identifying information about the woman who he had been following. He shared with the inpatient treatment team that he also was having homicidal ideation toward his former sergeant, who he felt had wronged him during his military service. Efforts to locate the individual named by Mr. S were unsuccessful. Mr. S further reported that several years earlier he had planned to abduct and murder his only friend's girlfriend because she was taking his friend away from him. The inpatient treatment team contacted the District Attorney's office in order to file for continued involuntary hospitalization due to the patient's homicidal ideation and history of violence. Subsequent police investigation and review of records could not substantiate any of the patient's claims of committing multiple homicides in the Pacific Northwest.
Despite his ongoing complaints of severe depression and psychosis, including a new symptom of hearing Italian opera in the hospital at night, Mr. S appeared calm and cooperative, demonstrated bright affect, exhibited good energy and sleep patterns, did not exhibit agitation or psychomotor retardation, was not seen responding to any internal stimuli, and was never confused or disoriented. Serial examinations found no evidence of a formal thought disorder or delusional beliefs.
After the District Attorney accepted the application for the prolonged involuntary civil commitment (180-day hold), Mr. S was confronted with the inconsistencies between his self-reported symptoms and objective findings and the failure to corroborate his claims of prior homicides. In response, Mr. S then confessed that he “had made the whole thing up…about the killings…all of it” because he “wanted attention.” He said that he had never followed, raped, or killed anyone and never had an intention to do so. He said that he did not know why he claimed this, other than an “impulse came over me and I acted on it.” He had believed that his feigned history and symptomatology would make him a “more interesting” patient to his therapist. He reported feeling rejected when his therapist transferred his care to her supervisor. He had little insight into why his therapist may have been frightened by his behavior. Mr. S revealed that following his initial fabrications, and despite his initial involuntary hospitalization, he had felt too embarrassed to admit the truth. He reported that the fear of being placed in prolonged civil commitment and the confrontation by the treatment team changed his mind. The clinical team shared with the District Attorney these developments and the revised clinical judgment about the patient's dangerousness, which was in turn shared with the court. Nevertheless, the patient did not contest his hold and the court certified the patient for the 180- day hold, which was completed in the hospital, at which time the patient was discharged back to outpatient care.
Mr. S's admission diagnosis was eventually revised from major depressive disorder, recurrent episode, severe with psychotic features to factitious disorder with psychological symptoms, and cluster A traits (particularly schizoid and schizotypal traits) without meeting criteria for any one specific personality disorder. Prior to the diagnosis of factitious disorder, treatment team had also considered patient to have a dysthymic disorder, as well as cluster A traits. Therefore, during his initial treatment course and prior to the diagnosis of factitious disorder, Mr. S's antidepressant was slightly increased to target his reported low mood; he subsequently reported immediate disappearance of auditory hallucinations and increase in his mood after only two doses of his slightly higher antidepressant dose. Upon evaluation and diagnosis of factitious disorder, Mr. S's antidepressant and antipsychotic medications were ultimately discontinued without any worsening of his mood or return of his “voices.” Off all medication for several months, he continued to deny homicidal ideation, depression, or perceptual disturbance.
Psychometric testing was performed to further explore his personality traits and confirm the clinical assessment and judgment that he was feigning all of his psychological symptoms. Results of the Millon Clinical Multiaxial Inventory, Third Edition (MCMI-III) were consistent with paranoid, schizotypal, schizoid, and borderline personality traits. The Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) profile suggested fabrication of psychotic and psychiatric symptoms and was invalid due to atypical responding (F scale > 120). The Miller Forensic Assessment of Symptoms Test (M-FAST), a semi-structured interview designed to detect feigning or significant exaggeration of psychiatric symptoms, showed slight symptomatic exaggeration that was below the range typically seen in those later judged to be malingering. Rorschach testing showed no evidence of a psychotic process, but instead suggested narcissistic, dependent, and borderline traits. Intelligence testing was not obtained during his hospitalization. However, Mr. S successfully served out two contracts with the military making it unlikely that he had a significant intellectual disability."