Have you ever seen someone lying? But as pathologically?

Pseudologia Fantastica in the Emergency Department: A Case Report and Review of the Literature - Robyn Thom MD, Polina Teslyar MD, Rohn Friedman MD

(Beth Israel Deaconess Medical Center: BIDMC Harvard medical school)

Have you ever seen someone lying? But as pathologically? Where they can’t stop lying up to a point where one knows he’s lying but keep going on? In this Journal of “Pseudologia Fantastica in the Emergency Department: A Case Report and Review of the Literature” written by three professors at Harvard medical school, they review one of the cases of their patient who has dealt with very unusual complex deception that psychiatrists don’t encounter often in the emergency department. Three physicians share their experience of meeting this patient who had this rare symptom to be seen and also, discuss ways of treating this disorder using a psychopharmaceutical approach and psychotherapy. Then finally they review the clinical characteristic of pseudologia fantastica and discuss how the patient they encountered aligns with the suggested diagnosis in those other clinical cases.

Breakdown:

• A simple outline of the case

• What is pseudologia fantastica?

• The key characteristics of “pseudologia fantastica”

• Then why do patients get pseudologia fantastica

• Treatment for pseudologia fantastica

• Conclusion

A simple outline of the case:

28 years old patient presented to the emergency room complaining about adnominal (lower stomach) pain and had multiple medical histories. His vital sign and lab result was expected and the emergency department was getting ready for a CT scan, then right before the CT scan, patient shared the story about how he has been struggling with depression and suicidal ideation due to the death of his pregnant fiancé. The emergency department was getting ready for surgery since the patient kept complaining about abdominal pain and they asked the psychiatry consultant team to quickly check the patient before surgery. After the CT scan, the imaging result has shown that surgery wasn’t necessary, and hence the patient was transferred to the psychiatry department to continue the consult. Then when the patient had a consultation with a psychiatrist, the patient requested placement at an inpatient clinic for ECT while claiming that he has been struggling with depressive feelings due to the death of his pregnant fiancé by a drunk driver eight months ago. But when the psychiatrist checked his medical record, it indicated that he only has been engaging for a month. Hence when the psychiatrist asked him to confirm the day of his fiancé’s death, he couldn’t recall. Then patient offered unrequired information about his social background and claimed his profession as a mathematics and physics professor at a prestigious university. But, when the psychiatrist asked about his research, the patient could only vaguely describe it by saying “time bends in space using some of Einstein’s old formulae.” He then continued to claim that he had a career as a varsity football player and cited that his injury was the source of chronic back pain and also the potential reason for his failure of being drafted by the national football league. But, just like before, when the psychiatrist asked him to provide collateral contact for verification, the patient claimed that both of his parents, multiple siblings, and cousins had died during his early childhood. Then very soon after, the department found out that the patient’s father was listed as an emergency contact in his medical record, hence contacting him for more information. They found out the patient has graduated with poor grades from a university that doesn’t have a division 1 football team, and his father confirmed that the patient had played football in high school and had sustained multiple concussions, and also the year after his graduation patient had lived with his parent briefly, but due to his escalated narcotic use and lack of employment, parents had to ask him to leave their house, and then patient became a homeless and unemployed due to usage of severe opioid dose. After, when the department obtained the information from the local emergency community the patient traveled to various hospitals within the city and even out of state to seek pain medication and care, and also told a similarly fictional narrative to other physicians. When the psychiatrist gently confronted the patient with these inconsistencies, the patient kept providing more elaborated details to explain them. But when he came down to a limitation, he simply shared that he believed he needed a “dramatic” reason to be depressed and he appeared to be perplexed as to why psychiatrists attempted to clarify his previous statements or their relevance for his care. In the conclusion, psychiatrists have agreed that this patient must suffer from a disorder called pseudologia fantastica or more easily called as “pathological lying.”

What is pseudologia fantastica?

Now then what is pseudologia fantastica? The term pseudologia fantastica was first suggested by the German physician Anton Delbrueck, in 1891 to describe the phenomenon of the group who lives in a way that is very extreme and fantastical with clear dissociation from reality to the listener but yet the patient themselves perceived as a realm of possibility

The key characteristics of “pseudologia fantastica” include:

• Chronic lying or storytelling that is not related to any clear objective benefit

• Story is very dramatic, detailed, complicated, colorful, and fantastic

• In the story, the patient himself is portrayed as a victim or hero in the narratives and seems to strive for achieving acceptance, admiration, and sympathy

• For the insight, the lie locates along the spectrum between conscious deceit and delusion and the paper describes this as “not always conscious of his motives and seeming at least intermittently to believe his stories yet never to reach the level of conviction that would indicate a loss of reality-testing”

*Many reviews of pseudologia fantastica have shown that patients who struggle with this disorder tend to have normal intellect but of superior verbal ability. Also, 40% of them had a history of a central nervous system abnormality such as epilepsy, abnormal electroencephalogram, head trauma, or central nervous system infection, and also at least 50% of them had demonstrated a history of visiting different healthcare institutions, and 25% of them has simulated the physical illness

Then why do patients get pseudologia fantastica?

Psychiatrists have identified a disorder as a compensatory way of enhancing self-esteem in the cases of facing shame. Hence from a psychodynamic perspective, fictional stories that are provided by these patients may be understood as a manifestation of the most natural defense again painful effects that are may be seen in a range of psychiatric disorders. Because not only do patients reject reality, but they also create a new reality that allows them to fulfill the wishes they had themselves. The temporary dissociation allows the drastic modification of one’s identity and that allows patients to relieve distress. One of the physicians summarizes this phenomenon saying that the psychic function of this false storytelling is not focused on achieving external goals or gains, but rather the patient himself feels gratification from associating oneself tightly with the communication of the false story itself. Where he specifically quoted “Communicating pseudologic daydreams as if they were reality serves the function of relieving the pseudologue of the obligations of real-life”

Treatment for pseudologia fantastica:

It is still very unclear and controversial when it comes down to the optimal management strategies for pathological lying. But there are still two possible treatments that seem to be used in many of the cases.

• Confront the pathological lying and patient’s deception (simply tell him the truth)

• showing disinterest in the story that the patient shares but maintaining the interest in the patient himself

And in many cases, psychiatrists shared the greater success with the latter strategy, and in fact, found out that confrontation resulted in increased frequency of pathological lying (patients provide more elaborated details to cover up the inconsistency they have in their narrative and reality)

Conclusion:

Understanding that patients themselves tell a false narrative as a way of dealing with their impaired self-esteem and that defense mechanism allowed them to oscillate between reality and fantasy, psychiatrists can increase their ability to establish rapport with those types of challenging patients. Also, if we share these ideas with people, we can prevent the people from thinking these types of patients are having bad personalities or attitudes but rather lying was a defense mechanism for patients to allow to deal with their own impaired self-esteem. Hence it will be amazing if our community becomes more open and understandable for people who are vulnerable to these types of disorders.