REGULAR ARTICLE A Case of Factitious

Christopher R. Thompson, MD, and Mace Beckson, MD

Homicidal ideation is often fabricated or embellished by psychiatric patients in both the emergency room and inpatient settings. Typically, this symptom is malingered to achieve short-term hospital admission and temporary relief from complications of , homelessness, and illicit activities. Very rarely, a patient may feign homicidal intent for the primary purpose of remaining in the role of patient (). Although factitious disorder with psychological symptoms has been described in a variety of circumstances, the psychiatric literature lacks any reports of factitious homicidal ideation. This is a report on the case of a patient who was civilly committed on numerous occasions for protracted periods based solely on his self-professed homicidal ideation. The case raises both forensic and clinical questions and reinforces the authors’ belief that further investigation is needed to develop more sophisticated methods of detection, evaluation, and treatment of factitious disorder with psycho- logical symptoms.

J Am Acad Law 32:277–81, 2004

“Danger to others due to a mental illness” is a char- Not uncommonly, homicidal ideation is malin- acteristic criterion for civil commitment in the gered to obtain short-term hospital admission and, United States. California state law provides for an consequently, temporary relief from complications initial involuntary 72-hour evaluation, an involun- of substance abuse, homelessness, and illicit activi- tary 14-day certification, and ultimately an invol- ties. Rarely, a patient may feign homicidal intent for untary 180-day certification for continued dan- the primary purpose of remaining a patient. We re- gerousness.1 However, retrospective analysis has port the case of a male patient who was committed demonstrated that individuals are rarely committed numerous times based only on his self-professed ho- for 180 days, especially when verbal threats are the micidal ideation toward unidentified individuals. sole rationale.2 The evaluation of dangerousness is complex and is reviewed extensively elsewhere.3 Case History Often, clinicians use the presence or absence of A middle-aged male was admitted involuntarily to homicidal ideation as a major part of their assessment a private psychiatric hospital for a 72-hour evalua- of dangerousness in the emergency room or inpatient tion for “danger to others.” Prior to admission, he settings. Because it is subjectively reported by the had informed his outpatient psychiatrist that he in- patient, homicidal ideation is easily fabricated. Fab- tended to murder four unnamed physicians who he rication or embellishment of symptoms for second- believed had provided him inappropriate or incom- ary gain (e.g., obtaining money, avoiding jail) char- plete medical and psychiatric treatment in the re- acterizes , while doing so for primary mote past. His plan to kill these individuals incorpo- gain (e.g., maintaining the role of patient) character- rated such details as the length of time it would take 4 izes factitious illness. to drive to the necessary target locations and the spe- cific firearms he would use to carry out the “mass Dr. Thompson is Forensic Psychiatry Fellow, University of California murder.” In consecutive examinations, the patient Davis, Division of Forensic Psychiatry, Sacramento, CA. Dr. Beckson is Associate Clinical Professor of Psychiatry and Biobehavioral Sci- vowed to follow through with his plan if released. ences, University of California, Los Angeles, and Medical Director, Therefore, he was committed to the hospital. Psychiatric Intensive Care Unit, Department of Veterans’ Affairs Greater Los Angeles Healthcare System, Los Angeles, CA. Ad- Further psychiatric history was gleaned from in- dress correspondence to: Christopher R. Thompson, MD, Univer- terviews with the patient and review of available sity of California Davis, Division of Forensic Psychiatry, 2516 Stockton Blvd., Suite 210, Sacramento, CA 95817. E-mail: treatment records. A limited number of records, [email protected] namely discharge summaries less than five years old,

Volume 32, Number 3, 2004 277 A Case of Factitious Homicidal Ideation were available through a centralized patient database the hospital, he presented again with the same chief linking the medical records systems of multiple hos- complaint, leading to the present civil commitment. pitals in a particular health care system. However, the The patient reported numerous psychiatric hospi- patient refused to divulge where he had received talizations in his lifetime and estimated having spent medical or psychiatric treatment prior to this time almost 50 percent of the past decade in psychiatric and, in any case, did not give us permission to con- facilities. During that time, he reported receiving a tact these unknown facilities. He also did not allow variety of psychiatric diagnoses including affective us to contact his family or friends, stating that he had disorders (major depressive disorder, bipolar disor- been estranged from his family for many years and der, ), anxiety disorders (obsessive-com- that he had “no friends.” pulsive disorder, posttraumatic disorder), a He eventually found work as a skilled laborer. The psychotic disorder (, de- patient suffered a knee injury at work that led to pressed type), and personality disorders (narcissistic, chronic pain and disability. Since that accident, he borderline). However, it was unclear from the avail- had been alienated from his family, had had no close able medical records how these conclusions were friends, and had not been involved in any meaningful reached. He had also had multiple trials of psycho- romantic relationships (he reported that he was tropic medications including antidepressants, mood heterosexual). stabilizers, and drugs (both typical and Approximately 10 years prior to the current ad- atypical). The patient noted that no medication had mission, the patient had seen a psychiatrist and com- alleviated his homicidal ideation, but had only plained of stress, pain, and severe anger. As a result, caused distressing side effects, for which he blamed his physicians. The patient denied any suicide at- he was hospitalized for several weeks for a diagnosis tempts or substance abuse. He claimed to have com- of with depressed mood. A few mitted several homicides in the past, but refused to months later, he was rehospitalized for a similar pre- provide details. sentation. He reported ongoing bitterness toward “injustices” he had suffered both at work and in his Hospital Course medical and psychiatric treatment. Over the next Findings in physical and neurological examina- four to five years, the patient had frequent contact tions at admission were normal. Bedside cognitive with the system and multiple psychi- testing revealed no deficits. Routine laboratory tests atric hospitalizations, generally precipitated by were unremarkable. Electroencephalograms (EEGs) “stress and anger” related to his aforementioned were normal in awake and drowsy states. Brain mag- treatment. netic resonance imaging (MRI) showed diffuse cor- A few years prior to the current admission, he had tical atrophy, predominantly along the cerebral con- been placed on his first 180-day certification at a vexities and in the temporal lobes bilaterally. The psychiatric facility for expressing homicidal ideation significance and etiology of the atrophy was unclear. toward unnamed prior treating physicians. He was The ventricles, basal ganglia, and other brain struc- rehospitalized at another hospital within the same tures were normal, and the patient did not demon- year for a similar presentation and remained hospi- strate any cognitive deficits, was not particularly im- talized involuntarily, on four consecutive 180-day pulsive or disinhibited, and had experienced no certifications, for a period of two years. During that significant personality change over the past decade hospitalization, he reported experiencing auditory (according to the patient and review of available (the quality of which is unclear from records). the records), , and depressive symptoms. Neuropsychological testing showed highly vari- However, the treatment records from this facility did able attention, concentration, and executive func- not indicate that clinicians had documented objec- tioning, as well as borderline verbal memory and hy- tive evidence supporting the patient’s reported symp- pothesis formulation. However, the patient’s full- toms. Nevertheless, he was subsequently diagnosed scale IQ was 132 (verbal IQ 135, performance IQ with schizoaffective disorder, depressed type, and be- 120). His Beck Inventory score was 39, gan to receive social security disability for this mental consistent with severe depressive symptomatology. illness. Less than one year following discharge from The Millon Clinical Multiaxial Inventory (MCMI)

278 The Journal of the American Academy of Psychiatry and the Law Thompson and Beckson was consistent with narcissistic personality character- murderous plans and testified to his homicidal ide- istics. The neuropsychological impression was of ation in mental health court on several occasions. “conscious symptom for primary or sec- After more than three months in the hospital, he ondary gain.” renounced any imminent homicidal intent, though Sequential examinations and ongoing close obser- he implied that he would “probably do something in vation of the patient in the ward milieu revealed no the future.” The treatment team concluded that the evidence of formal , hallucinations, patient was not a danger to others due to a mental or . Although the patient reported feeling disorder. Consequently, a recommendation was depressed, he was often observed to laugh and joke made to the court to discontinue his 180-day certifi- with other patients on the ward and did not display cation. The court agreed and the patient’s involun- or retardation. His appetite, tary hold was terminated. After the hearing, the pa- sleep, and energy were excellent. The patient’s anti- tient was confronted with our suspicions that he was psychotic medication was discontinued without embellishing or fabricating psychiatric symptoms complication. He was eventually treated with gaba- (namely homicidal ideation and depression). How- pentin for chronic knee pain and a selective serotonin ever, he denied this. He was offered continued vol- reuptake inhibitor for possible dysthymia, with mod- untary hospitalization on a different ward, but de- est responses to both. His physical complaints were clined and left the hospital the same day that his hold unchanged, despite consultation and treatment by was discontinued. the orthopaedic, physical medicine, and pain man- agement services. Discussion The patient repeatedly launched into accusatory After more than three months of evaluation while tirades about his mistreatment and made a specific the patient was involuntarily hospitalized, it was con- demand to “rectify” this mistreatment: government cluded that he was not a danger to others due to a subsidization of his “permanent hospitalization” at a . For over five years of having report- private community psychiatric facility. When in- edly similar thoughts, he had not acted on them. He formed that this request was unrealistic, the patient showed good impulse control on the ward. He had indirectly threatened his treating psychiatrists. Be- no history of making direct threats or attacks against cause the patient’s threats did not appear to be due to those he blamed for his problems. He did not exhibit an Axis I disorder, the treatment team contemplated a formal thought disorder or any other signs of psy- referring the matter to the police for possible crimi- chosis or agitation while hospitalized. Although the nal prosecution. However, although the patient al- patient reported feeling depressed, he was often ob- luded to the desire to kill four physicians who had served to laugh and joke with other patients on the treated him in the past, he never named anyone spe- ward. He did not appear anxious or agitated and cifically. Under the laws of the state of California, showed no . His appetite, prosecution for making terrorist threats requires the sleep, and energy were excellent. Therefore, it be- victim to “fear for his life,” which was not true in this came evident that his overall presentation was incon- case. We also considered attempting to warn the in- sistent with any of the major mental disorders neces- dividuals whom this patient had threatened to kill. sary for civil commitment. The treatment team’s However, the patient was uncooperative in releasing clinical impression was conscious embellishment, if older records of his prior psychiatric and medical not total fabrication, of homicidal ideation and de- treatment to us. Therefore, we were unable to iden- pression, motivated by his desire to remain in the role tify any potential victims. We contacted law enforce- of patient. Consequently, factitious disorder with ment officials about the possibility of issuing subpoe- psychological symptoms was the final diagnosis. nas to obtain all of his past treatment records but they We reached this conclusion after careful consider- were not interested in pursuing this course of action. ation of multiple factors. As mentioned previously, Despite the patient’s ongoing complaints, he ap- the patient did not demonstrate signs of a psychotic, peared comfortable and relaxed on the ward at all mood, anxiety, or substance abuse disorder. There- times. He remained focused on his perceived victim- fore, if the patient’s homicidal ideation were genu- ization and stated that those involved in his suffering ine, the only psychiatric diagnostic category that must ultimately die. He repeatedly alluded to his could be responsible for this continued symptom

Volume 32, Number 3, 2004 279 A Case of Factitious Homicidal Ideation would be a . We considered the talized indefinitely at a particular private inpatient possibility that the patient had a paranoid personality psychiatric facility. This indicates that the patient disorder, the presence of which may have made gen- believed “justice would be served” more fully by his uine homicidal ideation more likely. However, we receiving continuous caretaking rather than by his decided this was improbable for several reasons: acting on his reported homicidal thoughts. 1. This patient actively sought out psychiatric 4. Other features of the patient’s presentation are treatment and was quite forthcoming with his re- consistent with prior cases of factitious disorder. ported homicidal ideation. Individuals with para- These include: noid personality disorder do not generally seek out mental health treatment and tend to be reluctant to ● The patient presented to multiple hospitals in confide in others, because they fear that information different areas of the country. Peregrination is will be used maliciously against them.4 common in factitious disorder. 2. This individual seemed quite comfortable in the ● The patient left the hospital after being con- role of a psychiatric patient and did not appear to fronted with our suspicions that he was embel- think it was stigmatizing in any way. In contrast, lishing or fabricating symptoms. individuals with paranoid personality disorder are ● The patient has not returned to our facility. quite sensitive to perceived attacks on their character or reputation (e.g., being characterized as men- Obviously, another major diagnostic consider- tally ill) and are quick to react angrily or to ation was malingering, especially given this patient’s counterattack.4 history of manipulation for secondary gain (e.g., dis- 3. This patient’s MCMI was inconsistent with a ability income). However, this possibility seemed diagnosis of paranoid personality disorder. much less likely than factitious disorder for the fol- Although we concluded that this patient did not lowing reasons: have a paranoid personality disorder, we thought it 1. The patient spent two consecutive years under extremely likely that he had a narcissistic personality civil commitment based merely on his self-reported disorder and dependent traits. However, we strongly homicidal ideation. He could have recanted this at doubted that these were responsible for producing any time to be released. However, he appeared to genuine homicidal ideation. Rather, we thought that find pleasure in the role of patient and in being “in- his narcissistic personality disorder and dependent stitutionalized.” In fact, the patient’s expressed desire traits fueled his desire to remain well cared for in the was to be able to remain hospitalized indefinitely at a patient role and his fabrication or embellishment of particular private inpatient psychiatric facility. Ex- homicidal ideation helped him achieve that end. The tended civil commitment would probably be seen as following observations led us to this conclusion: a negative consequence by most malingerers (espe- 1. The patient’s MCMI was consistent with a nar- cially those with ample income) and something to be cissistic personality disorder. The patient’s history avoided rather than sought after. and clinical observations were indicative of a narcis- 2. Obtaining disability income did not lead to sistic personality disorder and dependent personality resolution of his reported homicidal ideation, which traits. This combination of personality characteris- continued despite the lack of any realistic additional tics is generally not consistent with prolonged genu- secondary gain. In addition, the patient probably re- ine homicidal ideation, but is consistent with facti- alized that ongoing contact with the mental health tious disorder.5 system (i.e., hospitalization) would only jeopardize 2. The patient’s behavior was not characterized by his disability income if his behavior were eventually the planning and execution of a homicide but rather diagnosed correctly. Therefore, he was risking previ- by the repetitive pattern of communicating a symp- ously acquired secondary gain to remain in the role of tom (i.e., homicidal ideation), being rehospitalized, patient. and sabotaging interventions designed to resolve that 3. The patient’s life appeared to be organized con- symptom. This indicates that the patient’s main goal sistently and continuously around his homicidal ide- was to be cared for continuously. ation and perceived victimization. This would be un- 3. The patient offered a concrete solution to his usual for true malingerers, who generally feign perceived unfair treatment, namely remaining hospi- symptoms intermittently at opportune times.

280 The Journal of the American Academy of Psychiatry and the Law Thompson and Beckson

4. The patient was savvy about psychiatric symp- study concluded quite succinctly, “It appears that toms and diagnoses. Extensive knowledge of medical acting crazy may bode more ill than being crazy.”5 or psychiatric terminology is quite common in facti- Ironically, these patients may have, in addition to tious disorder.6 their factitious psychiatric illness, another psychiatric 5. The patient’s MCMI was consistent with a se- disorder that may be responsive to psychotherapeutic vere narcissistic personality disorder, but showed lit- or psychopharmacologic intervention. Unfortu- tle evidence of antisocial traits. This profile would be nately, this idea is largely speculative, since most of more consistent with factitious disorder than malin- these patients leave the hospital abruptly once con- gering. fronted and are lost to follow-up. More investigation Although factitious disorder with psychological is certainly needed to develop more sophisticated symptoms has been described in a variety of contexts methods of detection, evaluation, and treatment of 7 8 (post-traumatic stress disorder, mourning, sexual factitious disorder with psychological symptoms to 9 10 harassment, and stalking ), review of the psychiat- minimize unnecessary psychiatric hospitalizations ric literature revealed no reports of factitious homi- and civil commitments. cidal ideation. The difference between factitious dis- order with psychological symptoms and malingering References is often subtle, and the continuum between uncon- 1. California Welfare and Institutions Code § 5.1.2.1-6 (2002) scious and conscious motivations (for symptom pro- 2. Weinberger LE, Sreenivasan S, Markowitz E: Extended civil com- duction) makes distinguishing the two quite difficult mitment for dangerous psychiatric patients. J Am Acad Psychiatry at times, even for the experienced clinician. Several Law 26:75–87, 1998 3. Gardner W, Lidz CW, Mulvey EP, Shaw EC: Clinical versus researchers have even questioned whether factitious actuarial predictions of of patients with mental illnesses. disorder with psychological symptoms is a mental J Consult Clin Psychol 64:602–9, 1996 illness.11 4. American Psychiatric Association: Diagnostic and Statistical Little is known about the incidence of factitious Manual of Mental Disorders (ed 4). Washington, DC: American psychological disorders, but three different studies Psychiatric Association, 1998 12 13 5. Pope H, Jonas JM, Jones B: Factitious : phenomenology, estimated that 0.14 percent, 0.5 percent, and 5.0 family history, and long-term outcome of nine patients. Am J percent5 of psychiatric hospital admissions are facti- Psychiatry 139:1480–6, 1982 tious in nature. Many authors contend that these 6. Kaplan HI, Sadock BJ: Factitious disorders, in Synopsis of Psy- chiatry (ed 7). Edited by Kaplan HI, Sadock BJ. Baltimore: Wil- patients are largely undiagnosed and hence are liams & Wilkins, 1994, pp 632–7 14 undertreated. 7. Sparr L, Pankratz LD: Factitious posttraumatic stress disorder. Our understanding of the etiology of the disorder Am J Psychiatry 140:1016–9, 1983 8. Snowdon J, Solomons R, Druce H: Feigned bereavement: twelve is based primarily on case reports. Generally, those cases. Br J Psychiatry 133:15–19, 1978 who feign psychological symptoms for primary gain 9. Feldman-Schorrig S: Factitious sexual harassment. Bull Am Acad come from distant, emotionally depriving families Psychiatry Law 24:387–92, 1996 and suffer from severe psychological dysfunction.15 10. Pathe M, Mullen PE, Purcell R: Stalking: false claims of victimi- sation. Br J Psychiatry 174:170–2, 1999 Cluster B personality disorders (particularly Border- 11. Rogers R, Bagby RM, Rector N: Diagnostic legitimacy of facti- line and Narcissistic types) and substance abuse are tious disorder with psychological symptoms. Am J Psychiatry 146: common.5 1312–4, 1989 Despite the fact that patients who present with 12. Nicholson SD, Roberts GA: Patients who (need to) tell stories. Br J Hosp Med 51:546–9, 1994 psychological symptoms are presumptively “closer to 13. Bhugra D: Psychiatric Munchausen’s syndrome: literature review treatment” (having initially come to a psychiatric fa- with case reports. Acta Psychiatr Scand 77:497–503, 1988 cility), there are few, if any, reports of successful 14. Popli AP, Masand PS, Dewan MJ: Factitious disorders with psy- treatment.5 In fact, research suggests that patients chological symptoms. J Clin Psychiatry 53:315–8, 1992 15. Eisendrath SJ, Guillermo GG: Factitious disorders, in Review of with factitious disorder have a worse prognosis than General Psychiatry (ed 5). Edited by Goldman H. New York: those with other major mental disorders. As one McGraw-Hill, 2000, Chap. 27

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