Pathological lying (also known as pseudologia fantastica or phantastica) has been associated with Munchausen syndrome since 1951 when Asher first coined the term Munchausen syndrome.1 The association was concretized in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), when factitious disorder diagnosis first came to light.2 Pathological lying and factitious disorder (sometimes used interchangeably with Munchausen syndrome) maintained their connection through various iterations of the DSM from DSM-III to DSM-IV-TR3 (including DSM-III-R4 and DSM-IV5). These versions of the DSM state that the best studied form of factitious disorder has been called Munchausen syndrome. They also state, in similar language, that individuals with factitious disorder with predominantly physical symptoms “may indulge in uncontrollable, pathologic lying, in a manner intriguing to the listener, about any aspect of their history or symptoms (pseudologia fantastica)” (Ref. 3, p 514). Surprisingly, however, the association between the two phenomena was dropped in DSM-56; there is no mention of pathological lying under factitious disorder.
Pathological lying and factitious disorder are poorly understood and controversial conditions. They are, however, real entities seen in regular psychiatric and medical practice, where they pose an enduring conundrum regarding their definition, etiology, investigation, and management. A review of the literature reveals a historical relationship between these two phenomena that not only questions the rationale for decoupling them in DSM-5, but in fact raises the even bigger question of whether the DSM Committee got the relationship between them wrong from the start.
In this article, I review the descriptions of pathological lying and factitious disorder (Munchausen syndrome) in the literature, highlighting the salient presenting symptoms and features. Further, I present highlights of a recent case reported in the media where both phenomena were prominently described. I will then propose a radical shift in the relationship between factitious disorder and pathological lying.
Pathological Lying (Pseudologia Fantastica)
Pathological lying was first described by the German physician Anton Delbruck in 1891.7 Although it is still not recognized in the DSM as a free-standing diagnosis, there is no disagreement in the literature on the core elements of the phenomenon. They include lies that are excessive, extensive, and repeated for no apparent purpose, external motive, or benefit; are easily verifiable to be untrue; may be elaborate, fantastic, or dazzling; may last years or even a lifetime; may be an end in itself; and may even be damaging to the liar.8,–,10 It has been observed that when there appears to be an external reason for lying, the lies are so grossly out of proportion to the apparent gain that they appear senseless.
Also, it is notable that the magnitude, frequency, or consequences of the lies (to the liar or to others) do not influence or apparently perturb the liar. Further, the lies are so firmly held that it appears the liar believes them to be true. When vigorously and persistently challenged, pathological liars may admit to some of their lies, but, more likely, they will alter their lies slightly, change topics and proceed with more lies, or leave the vicinity.8,–,10 Some researchers have proposed that pathological liars do not have the ability to control their lies because the production of lies seems either impulsive or compulsive. There is, however, no evidence in the literature of impaired reality testing or any other underlying psychiatric disorder that could account for the behavior.
Factitious Disorder/Munchausen Syndrome
In 1951, Richard Asher, a British hematologist and endocrinologist (who incidentally, also coined the term myxoedematous madness) first described “a common syndrome which most doctors have seen, but about which little had been written” (Ref. 1, p 339). He observed, “Like the famous Baron von Munchausen, the persons affected have always traveled widely, and their stories, like those attributed to him (Baron Munchausen) are both dramatic and untruthful” (Ref. 1, p 339). Accordingly, Asher coined the term Munchausen syndrome to describe the condition. In addition to frequent lying, patients with Munchausen syndrome characteristically travel from hospital to hospital, across regions, states, and even countries. Interestingly, the connection between Baron von Munchausen and the condition that was named after him is the presence of dramatic and fantastic tales of untruths and travels. There is no evidence that the Baron presented with tales of acute illnesses requiring hospitalization. In fact, it seems what the Baron apparently displayed could more accurately be described as pathological lying.8,11
Asher reported that patients with this condition (Munchausen syndrome) are admitted to the hospital with “apparent acute illness supported by a plausible and dramatic history … largely made up of falsehoods” (Ref. 1, p 339). He stated that the “most remarkable feature of the syndrome is the apparent senselessness of it … these patients often seem to gain nothing except the discomfiture of unnecessary investigations or operations …. Many of their falsehoods seem to have little point. They lie for the sake of lying” (Ref. 1, p 339). Asher observed that it is only over time that “the true history is pieced together, and the patient's own story is seen to be a matrix of fantasy and falsehood, in which fragments of complete truth are surprisingly imbedded” (Ref. 1, p 339). Asher reported that the patient's past history “may consist solely in innumerable admissions to hospitals and evidence of pathological lying” (Ref. 1, p 339).
Other researchers have corroborated Asher's obs-ervations, including the characteristic features of Munchausen syndrome: factitious illness with dramatic and emergent presentation at admission, pathological lying, peregrination (i.e., frequent travels), and many hospitalizations, among others.12,–,15 These descriptions were maintained in DSM-IV-TR: “The most severe and chronic form of this disorder (i.e., factitious disorder) has been referred to as Munchausen syndrome, consisting of the core elements of recurrent hospitalization, peregrination (traveling), and pseudologia fantastica” (Ref. 5, p 515).
Some clinicians propose that pathological lying (in Munchausen syndrome) is apparent when the “lies exceed all bounds necessary to deceive the doctor and establish the sick role …. The pseudologia (pathological lie) may take the character of playing a part where the patient takes on a whole new false identity, including name” (Ref. 15, p 168). The role may also be characterized by grandiosity where the patients attribute exciting jobs to themselves and tell fantastic tales about their own experiences and achievements.15 Bursten12 observed that, when patients with Munchausen syndrome are finally confronted with their lies and deceitful behaviors, they are typically unapologetic, will change their lies or invent cover-up stories, or suddenly and angrily discharge themselves from the hospital against medical advice, sometimes in the middle of medical or surgical interventions or observations.
Speculations regarding the motive for seeking treatment and engaging in pathological lies to achieve that goal have dogged the phenomenon from the start. Asher wondered if the motive included a desire to be the center of attention, a grudge against doctors and hospitals, a desire for drugs, to escape from the police, or to get free room and board for the night. The DSM-III (and later versions of the DSM) made clear that the reason for the intentional production (falsification) of psychological or physical symptoms and signs in factitious disorder was for the sole purpose of assuming the patient or sick role as exemplified by the lack of external incentives.2 The diagnostic criteria for factitious disorder begin with an intentional (conscious) production of psychological or physical signs and symptoms. In DSM-III-R, the behavior was described as not being under the control of the patient; it was compulsive in quality and could not be relinquished despite known dangers or adverse consequences.4
Highlights of a Media Case Report
In 2015, the Fort Worth Star-Telegram reported the case of Hope Ybarra, a former chemist and mother of three children who was arrested in 2009 and subsequently sentenced to 10 years in prison for a charge of serious bodily injury to a child.16 Over a period of four years, she had caused her second daughter (third child), born prematurely, to be subjected to multiple surgical and medical interventions from which she almost died. She caused the child to have a surgically inserted gastrotomy tube for feeding as treatment for a reported swallowing dysfunction, injected pathogens she stole from her lab to cause her daughter grave illnesses, altered her daughter's sweat tests leading to a diagnosis of cystic fibrosis, and drained her blood causing severe anemia. Her daughter went into life-threatening anaphylactic shock during infusion of iron dextran for her anemia. In all, her daughter received 30 to 40 surgical and medical interventions in the four-year span.
Earlier, Mrs. Ybarra had informed her family that her first daughter (second child) was born with cerebral palsy and had placed ankle braces on her intermittently for over one year. After the premature birth of her second daughter, however, her focus shifted, and the cerebral palsy was miraculously cured. Mrs. Ybarra had also been suspected of poisoning the water of two of her co-workers at the pharmaceutical company where she worked as a lab director; after they developed a mysterious illness, pathogens were cultured from their water bottle that implicated Mrs. Ybarra. She later lost her job when it was discovered she did not have a PhD as she had stated in her resume.
But Mrs. Ybarra's problems did not start with her daughters. She had a longstanding history of frequent lying behavior for no apparent reason. Right after her marriage in December 1998, she told her husband she was taking classes for her PhD. She left home for classes on Tuesday and Thursday nights for one year, after which she announced that she had obtained her PhD. Her husband was surprised she could accomplish that feat in one year despite doing it part-time, but he was proud of her accomplishment. He reported that she had printed PhD on everything, including business cards and in her email address. In 2001, she informed her family that she had just been diagnosed with bone cancer, and for the next eight years, “her cancer ruse grew more elaborate. She'd claim it had spread to her brain and lungs and destroyed her hearing, prompting her to learn sign language and, later, reportedly get a cochlear implant. She told people she beat the cancer twice and even moved to Alabama for eight months for treatment she said she could get nowhere else.” 16 The picture of a bald woman (she had shaved her head) undergoing chemotherapy while also taking care of a child with terminal cystic fibrosis was impressive in media interviews and attracted wide attention and sympathy. But these were all false. Although media attention brought her money and gifts worth over $100,000, she indicated that financial reward was not the primary motivation for her behavior as she and her husband did not lack for money.
While reportedly undergoing chemotherapy, she announced to her family that she was pregnant with twins. She wore maternity clothes, named her unborn twin girls and prepared everyone for their arrival. Then, one day, she suddenly informed her family that she had miscarried the twins at five months of pregnancy due to complications of her cancer treatment. She held a “mini funeral” for them and took a large sum of money from their bank account to have the twins cremated, after which she kept a sealed urn of their ashes on their fireplace mantle. She later bought a six-foot concrete angel for a memorial garden in their backyard and tattooed angel wings with five stars on her back, each star representing one of her five children, including the twin girls she reportedly miscarried.
Mrs. Ybarra's lies were numerous, unfounded, and often illogical. In some instances, they provided an opportunity for her to assume a sick role or to be the center of medical attention (for example, her reports of loss of memory and a diabetic coma with subsequent brain injury from which she miraculously recovered two days later). In other instances, however, there were no apparent benefits. Yet, in all instances, the negative consequences of her behavior far outweighed whatever benefit or goal that could be gleaned. Years later, during her interview by the Star-Telegram reporters while serving time in prison, Mrs. Ybarra continued to present her lies as true despite overwhelming evidence to the contrary. For example, she carried a yellow card that identified her as a hearing-impaired inmate and “initially spoke as a deaf person would, dotting her conversation with sign language …. As the interview continued, however, the speech impediment quickly waned, resurfacing only after she was asked whether she is hard of hearing or if it's just another ruse.” 16
Discussion
Pathological lying and factitious disorder have a lot in common; they are both controversial and baffling to clinicians. They involve frequent lies and deceptiveness for no apparent purpose or gain; where there appears to be a purpose, such as to assume a sick role in factitious disorder, the cost to the patient in terms of painful and stressful medical and surgical procedures far outweighs the apparent gain of being in a sick role.13 As in factitious disorder, the lies in pathological lying can also be self-destructive, but in either condition, negative personal consequences are not a deterrent for the behavior. In both conditions, the lies and deceptive behaviors are senseless, may be fantastic or even grandiose, told for a lifetime, and are difficult to give up. When vigorously challenged, they may slightly alter their lies or run away; the factitious disorder patient will leave the hospital against medical advice to proceed to another hospital within or outside of the region. In both conditions, it is questionable whether the individual has control of the behavior.
While in pathological lying the lies are broad and varied and with no consistent singular focus, in factitious disorder, they are more consistently focused around psychological or physical symptoms. It would therefore seem that pathological lying is the superordinate category and factitious disorder a subset of the condition with a narrower medical or psychological focus. Even in factitious disorder situations where elaborate lying (pathological lying) is not apparent, the core elements of factitious disorder (i.e., deceptiveness, senselessness, damage to self rather than apparent gain, apparent lack of ability to control behavior, and travel rather than admit the lies or deceptiveness) are all recognizable elements of pathological lying. Therefore, in my opinion, pathological lying is not a symptom of factitious disorder, but rather, factitious disorder is a narrower and more focused form of pathological lying. That factitious disorder is recognized as an entity in the DSM but pathological lying is not is an inexplicable oversight. This apparent contradiction is not difficult to understand, however. While clinicians can ignore individuals with pathological lying (until their behavior causes them trouble with the law or social and employment difficulties), they cannot ignore patients with factitious disorder who consume an exhausting amount of staff time, cause great disruption, and drain the physical and emotional reserves of clinicians, as well as the financial resources of systems tasked with taking care of them. Yet individuals with pathological lying also deserve clinical attention, especially because both conditions present the same dilemmas of management. It is long overdue for pathological lying to be accorded the recognition it deserves by mental health clinicians and elevated to a diagnostic entity on its own merits in the DSM, complete with a reexamination of its relationship with factitious disorder. Only then perhaps, would Baron von Munchausen's name finally be associated with a disorder that aptly describes him (i.e., pathological lying) and not factitious disorder.
Footnotes
This version of the editorial was posted online October 21, 2022, correcting an editorial error in the description of pathological lying on page 431 of the version originally published.
Disclosures of financial or other potential conflicts of interest: None.
- © 2020 American Academy of Psychiatry and the Law
