Does Pathological Lying Warrant Inclusion in DSM?

Pathological lying has rarely appeared on the psychiatric radar screen in recent years, remaining a poorly understood concept with serious ramifications, particularly for forensic psychiatrists.

Charles Dike, M.D., a forensic psychiatrist and clinical instructor in psychiatry at Yale University School of Medicine, maintains that psychiatrists need to pay attention to pathological lying so they are able to inform the legal system about whether pathological liars should be held responsible for their behavior. He believes as well that it is time for psychiatrists to assess whether pathological lying “represents only a symptom of a pre-existing psychiatric disorder or is a coherent enough entity” to be included as a separate diagnosis in APA’s Diagnostic and Statistical Manual (DSM).

Dike and his colleague Ezra Griffith, M.D., a professor of psychiatry and African-American Studies at Yale, addressed these issues at the annual meeting of the American Academy of Psychiatry and the Law in October.

Dike emphasized that the paucity of literature references and studies on pathological lying—which is sometimes referred to as pseudologia phantastica—should not be interpreted to mean that psychiatrists rarely encounter it in clinical practice. “Rather, it may be that psychiatrists simply know little about the subject and have difficulty recognizing the phenomenon,” he said.

Defining the concept is a crucial step in analyzing the concept of pathological lying from a psychiatric viewpoint, and Dike described it as repeated lies told over a number of years for which an external reason is not easily discernable. These lies are often “woven into complex narratives,” he pointed out. “In pathological lying, telling lies may often seem to be an end in itself . . . .the pathological liar may become a prisoner of his lies, [and] the desired personality of the pathological liar may overwhelm the actual one.”

Unplanned, Impulsive

Unlike other forms of lying, pathological lying appears to be unplanned and impulsive, he explained. “It is questionable whether it is always a conscious act and whether pathological liars have control over their lies.”

Whether pathological liars are aware of the falsehoods embodied in their stories has substantial implications for forensic psychiatry practice—for example, it could help determine how a court may deal with pathological liars who provide false testimony while under oath. It could also affect competency determinations.

“In a hearing about competency to stand trial,” Dike asked, “could it be argued that the compulsively repeated lying prevents the pathological liar from effectively assisting in his case?”

He also noted that agreement by psychiatrists on the factors that characterize pathological lying and differentiate it from related behaviors could have clinical implications as well.

Dike said that pathological lying can generally be differentiated from other psychiatric conditions associated with lying, including malingering, in which the lie stems from an identifiable “external incentive” in an intentional attempt to exaggerate or create physical or psychological symptoms. It can also be differentiated from confabulation, “a falsification of memory occurring in clear consciousness in association with organically derived amnesia. The patient attempts to cover exposed memory gaps with the confabulated materials,” he said. There is no organically based amnesia propelling pathological lying.

The false beliefs of delusions stem from affective or psychotic disorders and are held “despite incontrovertible evidence to the contrary,” Dike stated. Pathological liars may admit the falsehoods they’ve told when confronted and often proceed to change their stories. As a result, it may not, however, always be simple to distinguish pathological lying from delusional disorders. Pathological lying can be differentiated from factitious disorder, because taking on a “sick role” is clearly the goal, and the pathological liar does not want that label, he noted.

Some could confuse narcissistic personality disorder with pathological lying, but in the former “lies are told mainly for self-aggrandizement, and this is often obvious to the audience,” he pointed out.

One area in which the differentiation is not clear cut is borderline personality disorder, he said. “Pathological lying is not uncommon in patients with borderline personality disorder [in which] the core characteristics foster falsifications.” Reality distortions common to this disorder, “along with lack of impulse control and the defense mechanisms of denial, idealization, and devaluation, are fertile grounds for pathological lying.” Despite its relationship to this and a few other psychiatric illnesses, however, most examples of pathological lying appear to occur in the absence of a diagnosable psychiatric disorder, according to Dike.

If pathological lying is in fact a psychiatric disorder, Dike stressed that using the definition he and Griffith proposed, researchers could collect data in a systematic way “to determine the core symptoms of the disorder, possible etiological factors (psychological, organic, or both), and the effect on the sufferer’s level of functioning.” Once such clinical data are gathered, researchers could then assess whether pathological lying exists across cultures, if subtypes of the disorder appear to exist, and, most important, whether these liars “present with enough predominant, consistent, and stable symptoms or symptom clusters to delineate clearly a clinical entity fit for individual classification and DSM.”

Treatments

Should the case appear strong for it to be a disorder for the nomenclature, a next crucial step would be to study the effectiveness of treatments, both psychotherapeutic and psychopharmacological, he noted. “Research in this area could fruitfully include the use of radioimaging and other studies for diagnosis,” Dike said, “and a systematic study of the effectiveness of pharmacotherapy, psychotherapy, or the two in combination.”

For forensic psychiatrists whose advice on pathological liars the courts may seek, Dike advised taking an “extensive, longitudinal history of the lying” supplemented by related information from relatives, employers, friends, and others familiar with the person’s behavior over the long term. Crucial to this assessment, he said, is to clarify “external and internal objectives of the liar.” A well-structured psychiatric evaluation of a pathological liar would evaluate the “diagnostic entities potentially associated or confused with pathological lying.”

With the information he presented at the American Academy of Psychiatry and the Law meeting, Dike maintained that forensic psychiatrists may be able “to help attorneys frame an argument that justifiably presents their clients in a more favorable light, because the clients’ pathological lying is at least somewhat understood by relevant authorities.”

Dike acknowledged, however, that once data to establish whether pathological lying is a distinct disorder are evaluated, it may turn out that it’s just “a behavioral symptom and not a diagnosis.” But without clinical and research data, the syndrome, whether disorder or symptom, remains a psychiatric puzzle. ▪

Am J Psychiatry 2002 159 2105