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Comprehensive Psychiatry xx (2014) xxx – xxx
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Pseudologia fantastica: Forensic and clinical treatment implications

Panagiota Korenis a, b,⁎, Luisa Gonzalez b, c , Bashkim Kadriu d , Anu Tyagi d , Azuka Udolisa d
a
Residency Training, Department of Psychiatry, Bronx Lebanon Hospital Center, Bronx, NY 10456
b
Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY 10461
c
Inpatient Psychiatry, Bronx Lebanon Hospital Center, Bronx, NY 10456
d
Albert Einstein College of Medicine, Bronx Lebanon Hospital Center, Bronx, NY

Abstract

Pseudologia fantastica, also known as mythomania, or pathological lying, is a psychiatric phenomenon that is a mixture of fact and fiction
involving fantasized events and self aggrandizing personal roles. It has been recognized in the field for over a century. In this case report we
discuss three different cases, two of them presented in the acute inpatient setting and one outpatient setting. All three presented with the
common theme of extensive and ‘pathological lying’ in a manner that was notably very destructive to them and posing significant challenges
to the treatment team. In an attempt to shed light into some of the clinical and legal/forensic challenges it creates when faced in the clinical
settings, we also raise the need for a better definition and classification of this symptom in the DSM.
© 2014 Elsevier Inc. All rights reserved.

1. Introduction Indeed, chronic and compulsive lying alone does not

make up the characteristic features of PF. In addition to the
Pseudologia fantastica (PF) also referred to as “mytho- duration of the lying, the content in PF is distinct in that it
mania”, “deception syndrome”, “pathological lying” is may appear to be fantastic and extreme in nature to such
defined as a disproportionate falsification that may be extent that it may be perceived by the subject within the
extensive, complicated, and presents over a period of years realm of possibility, while to the observer it will seem highly
or even a lifetime. It first appeared in the medical literature in implausible. In addition, the underlying motive of the
1891 by the German physician, Anton Delbrueck [1] who pseudologue is unclear. In contrast to a “normal lie” which
coined the term after he observed that some of his patients has a goal directed path, PF may seem purposeless. PF is thus
told lies that were so abnormal and disproportionate to reality thought to be driven by unconscious motives rather than
that he could not classify them in any existing disorder. In external secondary motives like you would observe in a
general, essential components of a lie include an intent to normal lie. While it is thought to be a rare phenomenon it has
deceive and a conscious understanding of its fallacy. While been well documented in numerous case reports worldwide.
lying is part of human nature seen in both childhood and Akimoto et al., 1997 and Dice et al., 2005 note that a better
adulthood, PF bears some distinction in that it has been noted understanding and exploration of PF are necessary to bring a
to be excessive and chronic, presenting from early better awareness of the implication that untruths have on
adolescence and persisting into adulthood [2]. In 1998 legal, medical and social consequences [4].
Hardie et al. showed that it can often appear impulsive with While it has not been recognized as a disorder for over a
an element of ‘dyscontrol’ [3]. Further, they proposed the use century PF could not be accommodated in the criteria of the
of the term ‘deception syndrome’ for individuals who Diagnostic and Statistical Manual of Mental Disorders (DSM)
pathologically deceive for internal (i.e. psychological) as as a separate entity and is still often found associated with other
opposed to external reasons such as financial gain. disorders including antisocial, borderline personality disorder
and post traumatic stress disorder. It is most often associated
with factitious disorder, which was first included in DSM III in
1980. In factitious disorder, there is an intentional production
⁎ Corresponding author. of signs or symptoms with unclear reasoning behind the
E-mail address: Korenismd@gmail.com (P. Korenis). behavior. Historically, the DSM characterized the patient as
http://dx.doi.org/10.1016/j.comppsych.2014.09.009
0010-440X/© 2014 Elsevier Inc. All rights reserved.
2 P. Korenis et al. / Comprehensive Psychiatry xx (2014) xxx–xxx

being “motivated to assume the sick role” as an explanation for alleged suicide attempt by using a gun. As per patient reports
the symptom production. Unlike malingering, there is no it all started in context of the death of his wife and daughter
obvious motivation or secondary gain for exhibiting this in a recent motor vehicle accident. He described different
behavior and unlike conversion disorder, the signs and versions of the suicide attempt. In one scenario, he claimed
symptoms are consciously produced rather than unconsciously. he put a gun to his head and pulled the trigger with gun
The most severe presentation of factitious disorder is misfiring, while in another version he contemplated pulling
Munchausen's disorder. Named after the German Baron who the trigger but his son interrupted the attempts and took the
in the 18th century was famous for telling “tall tales” of his gun from him. He reported then throwing the gun into the
travels and plights, patients with this severe presentation have river and walking to the hospital as he thought of it as a “safe
recurrent hospitalizations and present with dramatic, untrue and place.” While on the inpatient unit he alleged needing to be
improbable tales of their past experiences. Munchausen by discharged because he had to care for his adolescent twin
proxy is seen when the guardian or parent intentionally makes daughters and had to return to his lucrative real estate
their child ill resulting in hospitalizations for the child. endeavors, which included owning several buildings.
While in DSM IV-TR, it was classified as a stand alone Extensive collaterals were obtained revealing that his family
diagnosis and was not in any specific category. There have been members never died in a motor vehicle accident, nor did he
three notable changes to factitious disorder in the DSM V [5]. have a gun or own any lucrative real estate. Family reported
First, is its categorization. In DSM V it has been grouped under that mother was a nurse who was grooming him to be a
the heading: “Somatic symptom and related disorders.” The doctor and spent time teaching him medical terminology. His
second change has been the removal of the “motivation to family described him as a pathological liar from young and
assume a sick role.” Instead it has been replaced with: “deceptive he was “known to tell tales and exaggerate.” He reported to
behavior is evident in the absence of external incentives.” The have received numerous scholarships from high profile
third and final amendment includes the creation of subtypes: institutions such is MIT, Columbia and Princeton and that he
factitious disorder “imposed on self” and “imposed on others” has a Masters in Business and Administration; however, his
thus removing factitious disorder by proxy from the appendix. family denied any of these academic accolades. On
Pathological lying often occurs without any external psychological testing during admission he demonstrated a
motivation to lie. It often begins as habitual or compulsive pattern of inconsistencies. Within a few days of discharge
lying starting in childhood and is associated with other from our inpatient unit he presented to the medical
delinquent behavior or as a means to assert autonomy in face emergency room with leg pain claiming he “tripped over a
of lack of self-esteem [6]. Pseudologia fantastica is a mixture bunch of puppies” and immediately upon discharge from the
of fact and fiction involving fantasized events and self- medical emergency room he again presented to the
aggrandizing personal roles, which usually becomes retract- psychiatric emergency room.
able once they are confronted with the facts.
While there do exist case reports that discuss the possible 2.2. Case 2
motives driving pseudologia fantastica as well as its
complicated presentation, few studies have examined the This is a 39 year-old Hispanic man with a history of
psychiatric treatment complications and forensic implica- schizophrenia. He is single, unemployed with an extensive
tions when dealing with patients presenting with this unique history of violent behavior, including incarcerations and
symptom. The following case report illustrates three patients; hospitalizations both in psychiatric and forensic settings. He
two admitted to an acute inpatient setting and one to the was incarcerated for over twenty years after two charges of
outpatient clinic who presented with very different psychi- armed robbery in his teenage years. Upon release from
atric symptoms but all were observed to excessively and prison, he was living with family and was brought to the
chronically lie in a manner that was notably very destructive hospital after a physical altercation with his brother in law.
to them. All three cases posed many challenges to the Upon examination he was observed to be talking to himself
treatment team and brought up significant issues related to loudly, irritable and internally preoccupied. During the
psychiatric and forensic consequences. course of admission, he portrayed himself as a government
official, a volunteer fireman, police officer and a military
special forces operative. He further claimed to participate in
2. Cases extreme sports, working as a DJ in Europe and reported
being married three times with each wife dying. He claimed
All names in the below cases have been blinded and having three children all of whom died during infancy.
interchanged with case numbers to maintain the confiden- During his adolescence, he told the treatment team that he
tiality and integrity of our patients. killed a young girl accidentally and during his incarceration
2.1. Case 1 he murdered an inmate and was sexually assaulted.
Extensive collaterals revealed none of what he reported to
This is a 56 year old man with bipolar disorder who be true except that he had been raped and abused while
presented with worsening depression, suicidal ideation and incarcerated. MRI revealed an open defect through the right
 P. Korenis et al. / Comprehensive Psychiatry xx (2014) xxx–xxx 3

lamina papyracea with herniation of intra-orbital fat into the in their clinical presentations and manifestation of PF. Studies
right lateral ethmoid sinus. Findings were compatible with also show that PF is seen in those who have a fragile sense of
sequelae of prior traumatic brain injury. self and low self esteem. All three cases illustrated this
fragility. Case 2 held onto the lie that he had murdered
2.3. Case 3 numerous people perhaps to present a “tough guy” appearance
This is a twenty-three year old African American woman to compensate for his slim build and short stature which may
with a history of borderline personality disorder. She have made him a target and vulnerable to predators while
presented to the outpatient clinic for individual psychother- incarcerated. Case 3 believed and often said to her therapist
apy and management of affective dysregulation. She was that her life was “boring” and she “wished” she were someone
given up for adoption by birth parents at the age of three and else. In addition, others may lie to gratify their narcissistic
was subsequently placed in foster care and adopted by a needs as illustrated by Case 1 who incessantly lied about his
family until she was sixteen. At the age of ten she had two education and work history.
suicide attempts and continued to have varying suicidal There are two common types of lies, aggressive and
ideation throughout adolescence. When she was sixteen she defensive [8]. In aggressive lying, the person lies for vanity,
ran away from home and has been in and out of various revenge, exaggeration or false accusation. In the defensive
shelters. Throughout the course of treatment she claimed that type of lie, the person is trying to get your sympathy or is trying
her mother was executed in California in 2013 after being on to evade punishment or consequences. PF will typically
death row for 3 years for killing father and step father. Her present with the aggressive type of lying. In addition, the
brother was allegedly killed along with her younger sister pseudologue may make claims to achievements or have
who was murdered by their mother and buried in the connections to famous or influential people – a phenomenon
backyard of their home. She claimed to be one of twelve known as imposture. Those with PF may also peregrinate
siblings and the only sibling to not be incarcerated for which refers to the migration from place to place as adults or
murder or drug charges. She also reported having two running away from home as a child. This is more prevalent in
children – the eldest twelve years old and was the product of the male pseudologue. Both male and female pseudologues
rape by a sibling. Collateral records revealed none of what will simulate disease with a prevalence of 25%. Male
patient reported to be true except that she was adopted and pseudologues are more likely to be involved in legal problems
had one infant son only. and 20% are in some form of psychiatric treatment.

3.1. Treatment complications

3. Discussion
Treating these patients posed a significant challenge to the
treatment team. The above cases presented with stories that
The most extensive writing on pseudologia fantastica
were so fantastical, it was difficult to not only come up with the
since Delbrueck was done by Healy and Healy in 1915 [6]
appropriate treatment plan it also posed a challenge when
and King et al. in 1988 [7]. In Healy's review of one
trying to determine diagnosis and work toward discharge
thousand juvenile defendants and King's review of 72
planning. Inevitably, because of these challenges, the length of
documented case reports of PF, the findings suggest that
stay for both inpatient cases was significantly longer than
while lying is not a unique symptom, PF is. Healy and
average (case 1 four weeks and case 2 one hundred and ten
colleagues noted that 15% of male and 26% of female
days). In both cases a second opinion as well as psychological
juveniles lied, however, only 0.01% were truly identified as
testing was obtained and great lengths were made to acquire
exhibiting PF with a sexual prevalence among women
collaterals to corroborate the history that was presented.
demonstrating symptoms as early as puberty. Almost all of
the cases of PF had a turbulent home environment and were 3.2. Forensic implications
more likely to have a father who abused alcohol. Intelligence
was noted to be bimodal in distribution meaning that either Studies suggest that males with PF are likely to have
the PF was of superior intelligence or just below average encounters with the law particularly involving forgery,
intelligence. Of note, during psychological testing it was burglary and identity theft [9]. The criminal entanglement of
found that the verbal intelligence quotient was significantly the pseudologue may pose challenges to both attorneys and
higher than performance intelligence quotient suggesting a judges specifically because of the compulsive lies making it
non-dominant hemisphere dysfunction. In the majority of difficult to discern the truth. Because of this specific
cases, the pseudologue suffered from some form of CNS challenge, both attorneys and judges alike may request the
dysfunction including: epilepsy, abnormal EEGs, head expertise of the forensic psychiatrist. The challenge is then
trauma or CNS infection. for the expert to tease out the truth in the complex web of lies
Review of literature suggests numerous reasons for why and rule out malingering. Extensive collaterals and a
people with PF lie. One hypothesis is that it serves as a defense thorough longitudinal history are required and at times,
against the re-experiencing of a psychological trauma. In both even psychological testing. There is also a question of
cases 2 and 3 trauma seemed to have played a significant role competency to stand trial. One of the core components of
4 P. Korenis et al. / Comprehensive Psychiatry xx (2014) xxx–xxx

being competent requires that the defendant be able to work the medical literature. It poses plentiful challenges not only to
with the defense attorney in a meaningful way so that the the treatment provider, but may also have considerable social
attorney may optimally represent in his defense. If the and legal implications as well. The role of the psychiatrist as
pseudologue compulsively lies and is not in control of their expert in discerning and assessing these patients is decisive
behavior, are they considered competent to stand trial? The and requires significant diligence and attention to detail. The
forensic expert may be consulted to evaluate and give their psychiatric role varies depending on the setting. While, in a
expert opinion on this matter. clinical setting, the psychiatrist is faced with the obstacle of
developing a therapeutic alliance that can be complicated
3.3. Management and treatment of the pseudologue when faced with the task of acknowledging the fabrication. In
Treating those who present with pseudologia fantastica poses the forensic setting, the expert's is of a non-partial duty to the
many therapeutic challenges to the clinician. Resistance to judge to aid in ruling out malingering or assessing competen-
engage in treatment is a common obstacle for clinicians working cy. Further exploration and investigation into pseudologia
in mental health in general and it is far more challenging when fantastica are necessary to better understand its psychiatric
the patient exhibits symptoms that are ego syntonic as is the case manifestations and consequences.
with PF. Developing a therapeutic alliance with the pseudologue
and having them accept psychiatric treatment is by far one of the References
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