Introduction
Pseudologia fantastica (PF), commonly known as pathological lying or mythomania, is a psychiatric phenomenon characterized by persistent, pervasive, and often compulsive lying. PF involves the intricate crafting of highly exaggerated narratives across various domains of life, including personal background, accomplishments, and interpersonal connections. Individuals afflicted with PF earnestly subscribe to these fabricated accounts, often perceiving them as genuine truths.[1][2] Unlike conventional lying, which typically involves 3 key components—consciousness of falsehood, intentional act of conveying misinformation, and a predetermined motive—PF diverges in its presentation and is characterized by a sincere belief in the veracity of the fabricated narratives, rather than a deliberate and calculated attempt to deceive for specific gain or purpose.[3]
PF manifests as an excessive distortion of reality grounded in factual elements, involving prolonged and extensive fabrication of events over extended durations, often spanning years, and lacking predefined objectives. Characterized by the construction of ostensibly credible falsehoods intricately woven into a framework of reality, PF is distinguished by its consistency over time and absence of overt personal gain motives, instead marked by a propensity for exaggeration and a notable lack of control over the fabrication process.[4] The fabrications characteristic of PF stands in contrast to fixed delusions in that individuals afflicted with PF can acknowledge the falsehood of their statements upon confrontation with factual evidence. This differs from false fixed beliefs, known as delusions, wherein individuals persist in their erroneous convictions even when presented with incontrovertible evidence contradicting their beliefs, demonstrating an inability to recognize the falsehood of their assertions.[1][5]
Since PF was conceptualized in the late 1800s, it has not been recognized as an independent disorder.[6] According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), the condition is considered to be a feature of cluster B personality disorders, including narcissistic, antisocial, and histrionic types, or posttraumatic stress disorder (PTSD).[5] PF has been theorized to stem from low self-esteem. PF is most related to factitious disorder, which was a standalone diagnosis in the DSM-IV and is classified under "Somatic Symptom and Related Disorders" in DSM-5, characterized by producing physical or psychological signs or symptoms without external gain or clear reasoning behind them.[5]
"Pseudologue" is a term used to refer to an individual who engages in PF, meaning someone who habitually fabricates elaborate and exaggerated stories. The term is derived from the condition itself, where pseudo in Greek means "false or deceptive," and logue is derived from the Greek word logos, meaning "speech or discourse." Therefore, a "pseudologue" is essentially someone who engages in the behavior characteristic of PF. PF has significant forensic implications, particularly in examining a pseudologue's competency to stand trial, as they may deliver false testimony under oath. Currently, PF is not recognized as an official mental illness per the DSM-5. Having one symptom without a recognized disorder may pose a question in mitigation.[7][8]
With the existing limited data on PF, efforts to comprehend its prevalence, identify associated risk factors, and assess its impact on individuals and society are imperative. Through clinical recognition and the implementation of suitable management strategies, the adverse repercussions of pathological lying can be alleviated, potentially leading to improved outcomes for those affected by this condition.
Epidemiology
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Epidemiology
The scarcity of data on PF stems from its infrequent diagnosis and complex nature, coupled with the inherent difficulties in effectively managing the condition. PF manifests across different stages of life, with an average age of onset around 16, although initial reporting typically occurs at approximately age 22.[1] Adolescence and early adulthood include exploration of identity, social interactions, and an increased sense of independence, which may contribute to the development of PF.
Studies on PF show conflicting findings regarding gender prevalence, with some suggesting equal occurrence in both genders while others indicate a higher prevalence among males. Gender differences in PF prevalence have been inconsistently reported and may be influenced by sociocultural norms, societal expectations for honesty, and variations in deception across geographical regions.[9][10] Accurately determining prevalence is challenging due to PF often manifesting comorbidly, typically as a syndrome within the broader context of personality disorders, and because individuals with PF frequently avoid seeking treatment and may not disclose their lying behavior.[5]
Pathophysiology
PF may appear purposeless on the surface without motive, but the pseudologue often has unconscious motives, which may include a desire for autonomy, elevated self-esteem, power, a subconscious effort to fulfill a wish, or an attempt to repress a difficult reality. The lies in PF are fantastical and astounding, perceived by the individual as within the realm of reality, and may appear challenging to believe to an observer. These lies may reflect underlying desires of the pseudologue as an unusual form of wish fulfillment, evolving into a complex system of deception that continues to progress if unrecognized.[8] For the pseudologue, the boundary between fantasy and reality often blurs, leading them to believe in their deceptions, thus perpetuating the cycle with more conviction each time the behavior repeats. However, their capacity to accept the falsehoods as such remains intact when confronted with tangible evidence.[6][8]
Although the pathophysiology of PF is not well understood, it is neurobiologically linked to dysfunction in brain areas involved in executive functioning, impulse control, and emotional regulation, such as the prefrontal cortex and limbic system. This dysfunction could contribute to difficulties in inhibiting dishonest behavior.[11] Multiple case reports have shown that PF is prevalent in individuals with a fragile sense of self and low self-esteem. Certain personality traits may make individuals more prone to engaging in pathological lying, influencing how they perceive themselves and others and their motivations for dishonesty, such as seeking admiration or engaging in emotional manipulation.
Psychodynamically, the most common themes of lies serving inner conflicts in PF include:
- The aggressive type, where a person lies to fulfill vanity, seek revenge, exaggerate, or make false accusations
- The defensive type, where the pseudologue seeks the observer's sympathy.
A prevalent qualitative theme observed in numerous narratives is the bolstering of self-esteem as a compensatory response to feelings of shame.[11][12][13][14] Pseudologues may become impostors, claiming achievements or connections to famous or influential people. These narratives embody primitive defenses used to cope with distressing emotions commonly seen across different psychiatric conditions and personality disorders.
Dissociation, characterized by a temporary shift in personal identity to alleviate distress, is a crucial defense mechanism in individuals affected by PF. Pseudologues fluctuate between conscious deception and delusion, illustrating their inherent dissociative tendencies. Storytelling within PF alleviates the pseudologue from the burdens of real-life obligations.[6][10] As elucidated by Deutsh, the essence of storytelling in PF primarily centers on personal gratification rather than pursuing specific external objectives. Consequently, a notable pattern of relocating from one geographical location to another during adulthood is frequently observed among individuals with PF. Furthermore, research suggests a higher propensity for legal entanglements among male pseudologues, with approximately 20% of them engaged in various forms of psychiatric treatment.[6][10]
Environmental factors, including experiences of childhood trauma, neglect, or exposure to dysfunctional family dynamics, are potential contributors to the development of pathological lying. These experiences are pivotal in shaping individuals' perceptions of themselves and others and their coping mechanisms for managing stress and interpersonal conflicts. Additionally, societal norms and cultural expectations regarding honesty and deceit can significantly influence the prevalence and manifestation of pathological lying. For example, in cultures prioritizing self-enhancement, individuals may be more inclined to embellish their achievements or fabricate stories to present themselves more favorably.
Intelligence distribution among pseudologues exhibits a bimodal pattern, with individuals demonstrating either superior intellectual capabilities or slightly below-average intelligence levels.[15] Psychological testing has revealed a significantly higher verbal intelligence quotient compared to the performance intelligence quotient, suggesting dysfunction in the nondominant hemisphere. Additionally, the majority of cases involve some form of central nervous system (CNS) dysfunction, including epilepsy, abnormal electroencephalogram (EEG), head trauma, or CNS infection.[16] Notably, PF is considered a complex phenomenon with likely multifactorial origins, necessitating more research to fully understand its underlying pathophysiology. Treatment approaches often address underlying psychological issues, improve coping skills, and promote honesty and accountability in interpersonal relationships.
History and Physical
The recognition of PF as a distinct diagnostic entity within the DSM has been long overdue, especially given its overlapping features and relationships with factitious disorders and various personality disorders. The absence of formal evaluation criteria for PF within psychiatric discourse underscores the necessity for a comprehensive examination of this phenomenon, emphasizing the need for a dedicated white paper outlining its assessment and management protocols.
The evaluation of PF mandates a holistic and multidimensional approach to unravel the intricate interplay of psychological, behavioral, and neurological factors that underpin pathological lying behaviors. This process necessitates the cultivation of a solid patient-physician rapport and the implementation of structured interviews to elucidate the content, frequency, and underlying motivations of the individual's fabrications while also attending to their emotional state. Furthermore, keen observation of the individual's behavior and interpersonal interactions becomes instrumental in discerning subtle indicators of deceitfulness or inconsistency. Additionally, the assessment encompasses an exploration of comorbid psychiatric conditions frequently associated with PF, as discussed earlier.
Evaluation
Psychological testing, including personality assessments and cognitive evaluations, helps to uncover underlying psychopathology and assess mental functioning. Comprehensive blood work is essential to rule out medical conditions and substance use, including liver and kidney function tests, electrolytes, complete blood count, vitamin B12 levels, folic acid and vitamin D levels, urinalysis, and urine toxicology. Neurological assessments and imaging studies can investigate potential brain dysfunction or neurological conditions contributing to the individual's lying behavior. Collateral information from family members, friends, or healthcare providers is crucial for verifying the individual's history and gaining additional insights into their behavior.
Reframing PF as a condition affecting individuals with low self-esteem who use primitive defense mechanisms can help establish rapport and facilitate treatment. Overcoming treatment resistance and fostering a therapeutic alliance are crucial initial steps. Strategies such as acknowledging fabrications while preserving the therapeutic bond or adopting an attitude of indifference toward lies can be beneficial. Maintaining an unbiased stance, along with respect and professionalism, is essential when presenting collateral information or evidence that contradicts the pseudologue's narrative.
Treatment / Management
Management for PF typically involves cognitive behavioral therapy to address underlying issues and modify behaviors. Medications such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may help with comorbid conditions and associated symptoms of depression or anxiety. However, research on the subject is limited, and the optimal management remains unclear, as PF is not yet a standalone diagnosis.[8] Psychologically, studies have shown that displaying disinterest in the fabricated tales while maintaining interest in the patient's self has better outcomes than directly confronting the pseudologue about their deceptions. An aggressive approach has been shown to increase the frequency of storytelling.[12][17](B3)
Management of PF is challenging and requires coordination and intervention at the multidisciplinary levels. Determining a diagnosis, treatment planning, and discharge planning is multidimensional and multifaceted in PF, which inevitably increases the length of stay for these patients. Grey et al emphasize maintaining consistent positive regard in patient-therapeutic interactions.[18] Despite the challenges posed by the patient's longstanding history of deception, the treatment team maintained a strong rapport with the patient. This rapport facilitated the development of greater insight into his symptoms and encouraged him to seek appropriate ongoing treatment. Additionally, providing support and education to family members and caregivers can help mitigate the impact of PF on the individual's life and improve overall outcomes.
Healthcare providers treating patients with PF need to maintain high frustration tolerance, as the primary symptom of PF—lying—may lead clinicians to assume confrontational approaches that can cause patients to sustain their behavior rather than evoke change.[13] Capturing intrinsic motivations through a nondirect aggressive approach is crucial, as it builds trust and alignment.[19] Treatment outcomes can vary depending on the individual's willingness to engage in therapy and the severity of their condition. Consolidating treatment, reducing self-harming behaviors and substance use, and ensuring stable relationships are vital aspects of managing PF.[10][17](B3)
Differential Diagnosis
Diagnosis |
Motivations |
Definitions |
External Gains |
Internal Gains |
PF (not recognized as a DSM-5 diagnosis) |
Desire for autonomy, elate self-esteem, power, subconscious wish fulfillment, repression of reality |
|
None
|
Fulfillment of needs, avoidance of distressing truths. |
Factitious disorder |
Presentation of self in a state of sickness without any noticeable gains or external rewards. |
|
None
|
Fulfillment of need for attention or nurturing, escape from reality. |
Malingering |
Motivated by external gains such as avoiding work, evading criminal prosecution, obtaining financial compensation, or drugs. |
Intentional production of false or exaggerated symptoms. |
Avoidance of work, evading criminal prosecution, and obtaining financial compensation or drugs. |
None, as it is motivated by external gains. |
Delusional disorder/psychosis |
Complete conviction toward false beliefs. |
Fixed beliefs that are not amenable to change in light of conflicting evidence. |
None |
Escape from reality, avoidance of distressing truths.
|
Personality disorders (cluster B)
This includes borderline personality disorders (BPD), narcissistic personality disorders (NPD), and antisocial personality disorders (APD) |
|
|
Seeking admiration, validation, or personal gain (antisocial) |
Coping with feelings of inadequacy in maintaining relationships.
|
Factitious Disorder
PF lacks specific coding as a diagnosis in DSM-5. However, it has been associated with factitious disorder, commonly known as Munchausen syndrome, which encompasses scenarios where individuals present themselves as ill without any apparent external benefits. In contrast to factitious disorder, where individuals simulate sickness, whether physically or psychologically, PF does not inherently involve assuming a sick role. PF encompasses a broader spectrum of fabricated narratives extending beyond medical or psychological themes, intricately interwoven into the individual's reality. Thus, factitious disorder can be seen as a more narrowly defined subset of pathological lying, primarily centered on falsifying medical or psychological conditions.[20]
Malingering
According to DSM-5, malingering is characterized by the deliberate fabrication or significant exaggeration of physical or psychological symptoms, motivated by external gains such as avoiding work, evading legal consequences, or seeking financial compensation or drugs. In contrast, PF entails weaving theatrical tales without discernible external incentives or motives. Thus, PF diverges from malingering as it lacks the clear external motivations typically associated with intentional symptom fabrication or exaggeration.[5][8][4][5]
Delusional Disorder
Another important differential diagnosis to consider is delusional disorder or other psychotic disorders, wherein individuals hold steadfast convictions regarding their false beliefs. In contrast, individuals with PF typically do not maintain the level of conviction required for a delusion. When confronted with evidence contradicting their fabricated narratives, pseudologues often demonstrate a capacity to acknowledge reality, thereby distinguishing PF from delusional disorder or psychosis.[5]
Personality Disorders
PF encompasses various narrative themes, such as grandiosity, including professional, academic, and athletic achievements, underscoring a fantasy of admiration for success and power. Patients with PF often exhibit traits associated with cluster B personality disorders, such as borderline, antisocial, or narcissistic, and other personality disorder traits. Individuals with borderline personality disorder may engage in pathological lying as a coping mechanism for feelings of inadequacy, to maintain relationships, or to avoid abandonment. Conversely, those with narcissistic personality disorder lie to exaggerate their accomplishments or importance, seeking admiration and validation from others. Pathological lying is also prevalent in individuals with antisocial personality disorder, who may use deceit for personal gain or to manipulate others.[13][14][10]
Other comorbidities associated with PF include adjustment disorder with mixed anxiety and depressed mood, major depression with psychotic features, atypical dissociative disorder, bipolar disorder, schizophrenia, PTSD, anxiety disorder, somatization disorder, and hypochondriasis.[13][14][10][5]
Deterrence and Patient Education
Educating patients, families, and legal teams about the ramifications of compulsive lying and its potential effects on personal, professional, and social spheres is prudent. This education helps patients and their families develop a deeper understanding of the condition, make informed choices regarding treatment, and adopt self-care approaches. As a result, individuals with PF are empowered to navigate their condition more adeptly, fostering healthier interpersonal relationships and overall well-being.
Pearls and Other Issues
Individuals with PF may present to mental health professionals with a range of psychiatric symptoms and comorbidities. Understanding PF is crucial in clinical settings to differentiate it from other disorders, which may have similar presentations but distinct underlying motivations. Moreover, PF can significantly impact individuals' personal, social, and occupational functioning, leading to strained relationships, legal issues, and difficulty maintaining employment or educational opportunities.
PF also presents significant challenges in legal proceedings.[5] Although PF is not recognized as a mental illness in DSM-5, its impact on legal proceedings cannot be ignored. Educating legal representatives about PF and independently verifying defendant claims is critical, especially if the defendant affected with PF undergoes competency to stand trial and criminal responsibility evaluations. Individuals with PF may provide false testimony under oath, complicating judicial decision-making. Distinguishing PF-induced lies from ordinary falsehoods is crucial, requiring prosecutors' awareness to ensure fair consideration and mitigation for defendants.[19]
Individuals with PF may also engage in lying, which is unrelated to PF, for external gains. This can complicate assessments, especially when there is evidence of personal gain or other motives behind the deception, regardless of the presence of PF. Therefore, educating prosecutors about PF is advisable to ensure a nuanced understanding of the behavior. By providing prosecutors with a clear understanding of the condition, defendants with PF may receive more leniency or consideration in legal proceedings.[8][10][17] Thus, understanding the forensic implications of PF is essential for legal practitioners to navigate complexities and ensure just outcomes in legal proceedings.
Managing PF in individuals poses significant challenges for clinicians and allied healthcare professionals, as their deceptive behavior can strain therapeutic relationships. In addition, it is crucial to recognize underlying psychiatric disorders that may coexist with PF, which would require prompt diagnosis and treatment. Viewing PF as a construct that transcends conventional diagnostic boundaries and evaluating for comorbid psychiatric disorders are essential for comprehensive care.
Enhancing Healthcare Team Outcomes
Interdisciplinary coordination with family and community resources is crucial in diagnosing and managing PF. Establishing open communication channels between mental health professionals, the patient's family members, and outpatient support services is essential for effectively sharing information, addressing concerns, and observing the patient's behavior and symptoms.
Family involvement is paramount as it can offer valuable insights into the patient's longitudinal history, behavior patterns, and social interactions. Collaborative meetings involving family members, clinicians, nursing staff, and social workers can facilitate a comprehensive understanding of the patient's condition and aid in developing a tailored treatment plan. Outpatient resources, such as community mental health centers and support groups, are crucial in providing ongoing support and assistance to the patient and their family.
By collaborating effectively, mental health professionals, family members, and outpatient resources can provide holistic care and support to individuals affected by PF. This collaboration helps acknowledge and address subconscious thinking patterns, foster behavioral change, and promote better outcomes and quality of life.
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