The patient is a 51-year-old male obsessed with the president's private life. Kenneth S. arrived at this clinic involuntarily after he was found randomly harassing strangers near the White House.
The patient, who appeared agitated and distraught on arrival, complained: "No one will tell me their secrets." He was sedated and placed under observation.
HISTORY OF PRESENT ILLNESS: Present illness appears to have moved into an acute phase in January 1998 when the patient put a hidden tape recorder on an informant in order to find out whether an intern had had sexual relations with the president. Kenneth S. was also preoccupied with the question of whether the president asked the intern to lie about the sexual relationship.
Since then the patient has been trying to uncover more and more secrets. He attempted to force an attorney to reveal the confidences of a dead client. He sought to find out what gifts the president exchanged with the intern, although he was more curious about what bodily fluids they might have exchanged. He could not control his obsession: He tried to force Secret Service agents to disclose fantastical sex acts he insisted they had witnessed. He attempted to find out what books the intern read and demanded that her bookseller tell him. He tried to get the intern's own mother to reveal her daughter's secrets. He badgered one of the president's closest friends, asking him, again and again, whether or not the president has "a sex addiction." He ordered members of the president's staff to testify behind closed doors where he subjected them to repeated questions about the president's sex life. The patient's sex obsession is so overwhelming it has eclipsed another, previous obsessional interest in a tract of land somewhere in the woods of Arkansas.
PAST MEDICAL HISTORY: No known psychiatric history. No history of psychotropic medications or of emotional complaints. His other medical history is unknown.
PAST HISTORY: Kenneth S., born in a Texas town, is the youngest of three children. His father was a minister, and his mother was a strict disciplinarian. She is quoted as having said Kenneth S. "was spoiled because he was the baby. I had to get that out of him, and it took me some time to do that." He apparently had numerous contretemps with his mother. He was described by his schoolmates as an arrogant tattletale who often told on them to the teacher. He always wanted to be proper and resented any other children having fun, especially when the teacher was out of the room. In the '60s, when others wore love beads and dashikis, Kenneth S. Always wore coats and ties.
The patient had a mediocre record at a Christian college and then transferred to a different school. After graduating law school he held lucrative jobs, but gave up a lifetime appointment on the federal appeals court to work in government. He had hoped for a Supreme Court appointment but was passed over. Ever since that time he has been determined to uncover presidential wrongdoings.
INTERVIEW: The patient was congenial and seemed sure of himself. When asked what he has against the president's family, Kenneth S. responded that he had nothing against the daughter, but didn't like either parent. He felt that the president always seems to be having fun -- even on that recent trip to China. Kenneth S. hated the fact that the president never seemed frightened, serious, nor contrite. He said that the president is a glad-hander who gets away with everything, and that that's not fair.
MENTAL STATUS EXAM: The patient was oriented to time, place and person. He knew who the president is and what time he takes his pants off at night. His mood and affect were appropriate, subdued when talking about judicial setbacks and visibly excited when talking about getting the goods on people's private lives. He answered proverbs without self-reference, even the cryptic "People in grass houses shouldn't get stoned." His insight was poor, however, as he said he had been forced to leak information to the press because he was being maligned by the president's staff. The patient's judgment was seriously compromised: He seemed totally out of touch with the consequences of his prurient obsession.
FORMULATION: At first glance, Kenneth S. appears normal, even though he once posed for photographs carrying a garbage bag over his shoulder. However, when one takes into account the fact that Kenneth S.'s early desire to "get away with things" may have been repressed by his mother, a different picture emerges. We see a child growing up striving always to be good, to be proper, to do the right thing. He eventually became proper. He dressed conservatively, lived a good Christian life. He abhorred evil and spoke out against what he thought was wrongdoing. But unconsciously, the more he embraced propriety, the more he repressed any and all "improper" thoughts and impulses. He managed to keep his investigative fervor at bay until he realized he would never sit on the Supreme Court. He never recovered from that blow and still likes it when people say, "Here comes the judge."
Kenneth S. is a classic case of obsessional pseudo-objectivity and pseudo-logic; he uses both to keep his perversions secret. Usually perverse impulses remain repressed and stay in the unconscious. But in the case of Kenneth S. these impulses have emerged into consciousness and have been channeled into a relentless interest in the president and his sexual relationships.
His rigid superego masks serious hatred of intimate relationships. He is condemned to a state of neurotic dissatisfaction, for no amount of acquired information can satisfy his obsessional longing. His excessive curiosity about the sex life of the first family (unconsciously representing his parents) is a flimsy cover for his wish to destroy their intimacy.
It is necessary to describe the nature of self-deception in this patient. He is so out of touch with his voyeurism and perverse interest in the sex lives of others that he ignores his own behavior. When Kenneth S. denies part of his inner world, such as a desire to destroy intimacy in others, he begins to deny other feelings and impulses as well. The patient feels the world around him is hateful, as he remains unable to accept responsibility for any of his own destructive actions -- such as making inappropriate remarks to the press. He said these acts were a necessary response to having been attacked. This is when voyeurism slides into paranoia.
DIAGNOSIS: Obsessional Personality disorder (301.2 DSM IV) with voyeuristic and paranoid features.
TREATMENT PLAN: In any case such as this, insight oriented psychotherapy cannot be initiated until the pathological behavior is stopped. As long as the perverse curiosity continues, no change is possible. Therefore, Kenneth S. must be barred from his investigative role in order to help him control his destructive impulses. He might not require in-patient treatment in order to do this, but one cannot rule out that possibility, especially if he continues asking everyone he meets about the president's sex life. Treatment might be opposed by the members of Congress and the judiciary, however. In any event, Kenneth S. needs to uncover the early sources of his obsession in order to find relief and stop asking so many questions.