University of Maryland
Clinicopathologic Conference

A 36-year-old Renowned Military Officer

Davidge Hall
Lombard and Greene Streets

PRESENTATION OF CASE

The patient is a 36 year old, renowned, military officer, who in the face of convincing evidence of an overwhelmingly superior enemy force, orchestrates a defeat so severe that it culminates in the annihilation of his personal command of over 200 men, his own death, and the deaths of 2 of his 3 brothers, a favorite nephew, and a brother-in-law (1).

Early in his career, the patient was court-martialed for deserting his command and in the process, endangering the lives of several members thereof and destroying valuable government property. His reason for doing so was to be with his wife, for whom he was experiencing separation anxiety after only a month's separation (1). The patient exhibits no evidence of remorse over the deaths of several members of his command who he had been forced to abandon during a fierce engagement (1,2). Nor does he evince remorse after having been court-martialed for issuing a tacit "shoot-to-kill" order directed at deserters under his command. After one engagement, he is also reported to have denied wounded members of his command access to ambulances, which he used instead to transport his hunting dogs (1,2).

While a college student, the patient had a single episode of a sexually transmitted disease -- most probably gonorrhea (1). During this same period, he had numerous upper respiratory infections, 3 episodes of (infectious ?) diarrhea, an attack of shingles, and repeated headaches. Since then, he has had almost no physical complaints, except for first-degree burns of his hands, a gunshot wound to his lower leg, and a mild concussion, all incurred during his early twenties. He has no allergies and takes no medications.

The patient is the first surviving child of the second marriage of both his mother and his father (3). He has 5 siblings and 5 half-siblings and was raised in what, by all accounts, appears to have been a loving and devoted family environment. His father was both physically strong and a consummate practical joker. He has always been solicitous toward the patient. The patient's mother, although slight of build, is a strict disciplinarian who has dictated a stringent moral code within the family.

As a child, the patient was active (perhaps hyperactive), athletic, daring, and mischievous (1). By several accounts, he was his parents' favorite child (3). As an adolescent the patient spent several years living with an older half-sister, who he came to idolize (3). It was this half-sister's son who the patient led to his death in his final battle. At the urging of this half-sister, the patient eschewed alcohol and tobacco as an adult. As a teenager, the patient described himself as "above medium height and of remarkable construction and vigorous frame." He was decidedly impulsive, with a penchant for practical jokes, kind and generous to his friends, implacable toward his enemies, and completely open in his feelings. He "accepted Jesus" as an adolescent but has never been preoccupied with religion. During this period, he was chauvinistic regarding his country's contributions to mankind.

In many people's opinions, the patient now possesses most of the essential personal characteristics of the ideal military leader (1). He is gallant, immune to fatigue, impervious to fear, and maintains a clear head in danger. He is clearly excited by war. He is direct, honest, decent, and proud. He is also frequently pompous, impatient, and flamboyant. When leading men into battle, he characteristically has his regimental band play a favorite marching tune. He has a strong sense of personal destiny and believes himself bound for glory. He is an absolute authoritarian, which contrasts sharply with his attitude as a child, when he exhibited little respect for authority. At the same time, the patient has never lost his penchant for immature, and occasionally dangerous, practical jokes. He is optimistic by constitution. However, on rare occasions, he becomes moody, sometimes remaining silent for hours. He is simultaneously deeply sentimental, crying whenever he parts from his mother or watches a moving play, and thrilled by the killing of both men and animals. He has surrounded himself with family members and a few close friends, with whom he works closely and does the preponderance of his socializing.

The patient is married and has a highly stylized relationship with his wife, which is simultaneously deeply uxorious, manipulative, and immature (1). He signs his letters to her "Your Boy." He has had at least one extramarital affair, and perhaps more. He has no children. He is a career military officer, whose professional philosophy is "to do that which the enemy neither expects nor desires." He is an avid hunter and a compulsive gambler (the later avocation, in fact, has been a source of repeated financial difficulties). The patient is a college graduate, a serious student of history and an author of some talent (4).

The patient is well-developed, muscular, and handsome. He appears his stated age. His motions are rapid, as is his manner of speech. In fact, his conversation is so quick and energetic, that he frequently hesitates mid sentence, particularly when excited or angered, as if words cannot be formed fast enough to keep up with the thoughts which precede them. The patient appears to be in perpetual motion (e.g., eats rapidly, constantly pacing, etc.). He is fastidious in his personal hygiene. His physical examination is normal except for a well-healed bullet wound of the left lower leg.

PSYCHOLOGICAL TESTS

* The subject completed a series of self-administered psychological tests, including the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), the Millon Clinical Multiaxial Inventory-II (MCMI-II) and the Beck Depression Inventory (BDI)

(Footnote 1).
Validity scales of both the MMPI-2 and MCMI-II are consistent with serious responses from a cooperative subject. They also indicate a lack of significant distress on the part of the client as a result of the test process. Whereas MMPI-2 scores on both the "K" and "F" scales indicate a willingness to acknowledge experiences that might be viewed as aberrant, the patient's "L" or Lie scale suggests that his responses might have been affected by a desire to create a favorable image. The MCMI-II results reveal a debasement scale score of zero, reflecting strong resistance to acknowledging negative attributes. Although the MCMI-II results reflect generally open responses on the part of the subject, there is also a suggestion of a desire to appear "okay". The subject denies any symptoms of depression on the Beck Depression Inventory. His MMPI-2 clinical profile, overall, is within normal limits, except for Scale 5 (Masculinity-Femininity) which is significantly elevated, as is typical of homosexual males not trying to hide their homoerotic behavior. Although the Scale 6 (Paranoia) and Scale 9 (Hypomania) profiles are within the normal range, they are at the upper limits of normal. With adjustments for the subject's likely minimization of symptoms, these two profiles might be viewed as mildly aberrant. Results of the MCMI-II reveal a Profile 546: Narcissistic-Histrionic-Antisocial, consistent with a confident, dramatic, and competitive personality.

DR. DAVID B. MALLOTT'S DIAGNOSIS

Histrionic personality disorder.

FOOTNOTE

Two long-term students of the life of George A. Custer (BCP & LB) completed the Minnesota Multiphasic Personality Inventory-2 (MMPL-2), the Millon Clinical Multiaxial Inventory-II (MCMI-II, and the Beck Depression Inventory (BDI). These two Custer experts completed test questions as a team, answering questions the way they thought the subject would have answered them, rather than as historians examining the subject. In formulating answers to the questions, they drew heavily upon Custer's personal correspondences and other historical data.

Acknowledgements

The authors thank Barbara Alexander, M.D., Ph.D. and Thomas Ghiorzi, M.D. for their participation in this conference and Robin Hindsman, Psy. D. for analyzing the psychological tests. Supported in part by an unrestricted continuing educational grant from Bayer Pharmaceuticals and by the Department of Veterans Affairs. This case discussion was originally presented in an open forum sponsored by the University of Maryland School of Medicine and the VA Maryland Health Care System as part of a continuing series of historical clinicopathological conferences.

Table 1. Diagnostic criteria used to define personality disorders.
A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two or more of the following areas:
(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
(3) interpersonal functioning
(4) impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

Table 2. Criteria defining the histrionic personality disorder* (1) Discomfort in situations in which he or she is not the center of attention.
(2) Interactions with others often characterized by inappropriate sexually seductive or provocative behavior.
(3) Rapidly shifting and shallow expressions of emotions.
(4) Consistent use of physical appearance to draw attention to self.
(5) A style of speech that is excessively impressionistic and lacking in detail.
(6) Self-dramatization, theatricality, and exaggerated expression of emotion.
(7) Suggestiblity , i.e., easily influenced by others or circumstances.
(8) Tendency to consider relationships as more intimate than they actually are.
* Five or more required for diagnosis (9).

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