Factitious Disorder in a Patient Claiming to be a Sexually Sadistic Serial Killer.

Factitious disorder involves the conscious simulation of psychological or physiological symptoms of illness, for the purpose of fulfilling the unconscious desire to be taken care of or to assume the "sick role." Typically patients with factitious disorder simulate conditions that are designed to arouse feelings of empathy in care providers with the intention to engage them in caretaking. However, patients might also simulate conditions that arouse revulsion or rejection and still meet full diagnostic criteria for factitious disorder. In this case report, we present a patient who fabricated an elaborate history of being a sexually sadistic serial killer with homicidal ideation with the intention of obtaining personal attention, nurturance, and empathy from his psychotherapist. However, given the nature of his feigned condition, the patient frightened the very person whom he sought to engage in caretaking.

Brain maturation may be arrested in chronic cocaine addicts.

BACKGROUND: Animal and human newborn studies suggest that exposure to cocaine in utero delays glial maturation and white matter myelination. Postmortem data show that in the frontal and temporal lobes, white matter myelination continues into middle age. Recent magnetic resonance imaging (MRI) data have confirmed continued white matter volume increase in these regions, reaching a maximum at age 47. METHODS: Thirty-seven male cocaine dependent (CD) and 52 normal control subjects between ages 19 and 47 were evaluated with MRI. Coronal images focused on the frontal and temporal lobes were acquired using pulse sequences that maximized gray/white matter contrast. RESULTS: Highly significant positive correlations between white matter volume and age were observed in both the frontal and temporal lobes of the control group (r =.52, p =.0001 and r =.54, p =.0001, respectively); however, CD subjects did not demonstrate any age-related increase in white matter volume of the frontal (r = -.001; p =.99) and temporal (r = -.07; p =.67) lobes in this age range. CONCLUSIONS: The age-related expansion in white matter volume occurring in normal control subjects was absent in CD subjects. The findings suggest that in adults, cocaine dependence may arrest normal white matter maturation in the frontal and temporal lobes of addicts who continue using cocaine.

A case of factitious homicidal ideation.

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 substance abuse, homelessness, and illicit activities. Very rarely, a patient may feign homicidal intent for the primary purpose of remaining in the role of patient (factitious disorder). 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 psychological symptoms.

Commentary: Craving diagnostic validity in DSM-5 Substance Use Disorders.

Drs. Norko and Fitch examine questions raised by DSM-5 in the forensic context of criminal defendant diversion to treatment, where eligibility has commonly relied on the view that addiction to alcohol or drugs is distinct from alcohol or drug use, misuse, and abuse. The creation in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), of the new unidimensional spectrum diagnosis of Substance Use Disorder (SUD), which includes three Abuse criteria from DSM-IV, has resulted in a need to re-examine policies that evolved with the DSM-III-R/DSM-IV biaxial abuse-dependence conceptual paradigm. DSM-5 acknowledges the common usage of the term addiction to describe severe problems, and that some clinicians choose to use the word to describe more extreme presentations. Limiting the concept of addiction to the severe form of DSM-5 SUD would maximize validity and support for an expert opinion that an individual has an addiction, as well as facilitate research inquiry into the underlying psychobiological nature of addiction. However, in some contexts, such as criminal diversion, achieving such specificity at the expense of sensitivity may be undesirably restrictive if it excludes appropriate candidates. Future research and experience in both clinical and forensic settings are needed for a fuller understanding of the DSM-5 SUD diagnoses and associated real-world implications.

Male victims of sexual assault: phenomenology, psychology, physiology.

Myths, stereotypes, and unfounded beliefs about male sexuality, in particular male homosexuality, are widespread in legal and medical communities, as well as among agencies providing services to sexual assault victims. These include perceptions that men in noninstitutionalized settings are rarely sexually assaulted, that male victims are responsible for their assaults, that male sexual assault victims are less traumatized by the experience than their female counterparts, and that ejaculation is an indicator of a positive erotic experience. As a result of the prevalence of such beliefs, there is an underreporting of sexual assaults by male victims; a lack of appropriate services for male victims; and, effectively, no legal redress for male sexual assault victims. By comparison, male sexual assault victims have fewer resources and greater stigma than do female sexual assault victims. Many male victims, either because of physiological effects of anal rape or direct stimulation by their assailants, have an erection, ejaculate, or both during the assault. This is incorrectly understood by assailant, victim, the justice system, and the medical community as signifying consent by the victim. Studies of male sexual physiology suggest that involuntary erections or ejaculations can occur in the context of nonconsensual, receptive anal sex. Erections and ejaculations are only partially under voluntary control and are known to occur during times of extreme duress in the absence of sexual pleasure. Particularly within the criminal justice system, this misconception, in addition to other unfounded beliefs, has made the courts unwilling to provide legal remedy to male victims of sexual assault, especially when the victim experienced an erection or an ejaculation during the assault. Attorneys and forensic psychiatrists must be better informed about the physiology of these phenomena to formulate evidence-based opinions.

Variation in neurophysiological function and evidence of quantitative electroencephalogram discordance: predicting cocaine-dependent treatment attrition.

Cocaine treatment trials suffer from a high rate of attrition. We examined pretreatment neurophysiological factors to identify participants at greatest risk. Twenty-five participants were divided into concordant and discordant groups following electroencephalogram (EEG) measures recorded prior to a double-blind, placebo-controlled treatment trial. Three possible outcomes were examined: successful completion, dropout, and removal. Concordant (high perfusion correlate) participants had an 85% rate of successful completion, while discordant participants had a 15% rate of successful completion. Twenty-five percent of dropouts and 50% of participants removed were discordant (low perfusion correlate), while only 25% of those who completed were discordant. Failure to complete the trial was not explained by depression, craving, benzoylecgonine levels or quantitative electroencephalogram (QEEG) power; thus cordance may help identify attrition risk.

Cortical gray matter volumes are associated with subjective responses to cocaine infusion.

We analyzed the relationship between cocaine-induced euphoria and measures of frontal and temporal gray matter volumes in eleven cocaine-dependent (CD) patients who underwent magnetic resonance imaging (MRI). Self-reported ratings of the intensity of euphoric response to cocaine infusion were obtained from the CD subjects at 3, 10, and 30 minutes after cocaine infusion. Significant positive correlation between frontal and temporal cortical gray matter volume and the intensity of euphoria was observed at 10 minutes after IV cocaine. The data suggest that frontal and temporal lobe gray matter volume is associated with some of the reinforcing effects of cocaine. Given the well-established negative linear relationship between cortical gray matter volume and age, cortical gray matter volume may be a marker for the neurobiological substrate of the age-related reduction in addiction rates.