Pseudologia Fantastica

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

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]