My name is Charles D. Kaye. I am a professor of psychiatry and law at Yale University. I'm also the chief medical officer in the office of the commissioner, Connecticut Department of Mental Health and Addiction Services. This topic, pathological lying, has been in my bones and blood since I did my fellowship in forensic psychiatry at Yale 150 years ago. And it still remains relevant today. All right, so let me just start by... Conflicts, each time you work for the government, you want to say that everything I say is my opinion and not the government's opinion, also not Yale's opinion as well. And other than that, I have nothing else to disclose. We're going to go through a small journey here of a little bit of a history of pathological lying. Then we're going to look at some of the salient presentations and theories around it a little bit. Then I'm going to dive into some of what I say I think might be the reasons for thinking about pathological lying as a diagnostic entity. To help me do that, I will pull on the factitious disorder entity as well. And then at the end, I'll try to make a case, and then you guys can tell me if my case makes sense or it doesn't make sense. But before I start, I'd like to do a quick unscientific survey. If any one of you here told a lie yesterday or today, please raise your hand. Only a small number of people told a lie yesterday or today. Wow! I have never seen this before in the 110 years I've been talking about this. This is amazing. The question really is, what the heck am I doing early in the morning on Monday morning in front of a room full of liars? The fact, though, is that everyone lies, and you can't stop them. Of course, that's the truth. This is a saying by Saling, and it remains true today. I like this quote, there's no vice so mean, so pitiful, so contemptible. And he who permits himself to tell a lie once finds it much easier to do so a second time, a third time, until at length it becomes habitual. This was by one of our presidents, so many years ago, talking to his nephew. Now, there was a survey that was done some time ago of college students and adults in the city, and it said that college students tell an average of two lies a day, and adults tell an average of one lie a day. Therefore, lying is something that is really... I don't know what you guys are going to say. So let's try with some examples to get just at the corner of this discussion here. I would like to start with Professor Joseph Ellis. And this is a media report. He was splashed on the pages of the Boston Globe in 2001. Professor Ellis was a professor of history at Mount Holyoke College here in the U.S., a very prominent National Book Award winner, Pulitzer Prize winner in history, and so on. So lots and lots of prizes. But what was really remarkable about Professor Ellis, which was really shocking, is that his lies expanded as his fame grew. Most people, once you come out of school, your first CV has a lot of lies in it. There are things you haven't done, you're claiming you did. But the more you begin to do things and the more you get really prominent, the less those lies, you just drop them. However, what happened with Professor Ellis, which was really surprising, is that the lies expanded as his fame grew. It got to a point where he was exposed in a very, I would say, really difficult way by this Boston Globe article. And that led to his suspension for one year from his endowed professorship. I think he's come back now. Here's a pictorial representative of some of his wonderful lies. He claimed that he scored the winning touchdown in a high school football game. Problem is, he never played football. He claimed that he was a platoon leader and paratrooper. He had served a duty in Saigon in the Vietnam War. Problem is, he wasn't there. He also claimed that when he came back from the war, he joined the Civil Rights Movement and had this very dramatic description of what happened to him in Mississippi, where the local police were pounding on my door at night and the state police followed my car. All false. What he was doing instead, he was studying as a graduate student at Yale and then he went to West Point to teach history. That's what was happening in the era where he was describing himself in all these different scenarios. By the way, his course and his history class at Mount Holyoke was the most sought after by students. It was just fantastic. I think some of the stories helped, but it was really great. One of his students, upon learning about this fact from reading the Boston Globe, said, why should a man so successful as Mr. Ellis, whose books are those rare creatures, best-selling works of history, feel compelled to reinvent his past? He seemed so genuine. Perhaps it was a fantasy he had come to believe himself. This is the theme that will run through a lot of pathological line. Is it something that people have come to believe or is it something that they don't believe? Here's the next person, another prominent individual. He's Judge Patrick Cohenberg. Appointed a judge in LA, Los Angeles in 1997 and was removed from it in 2001. Why? Because he did exactly the same. Here he was, claiming that he was a corporal in the Army, that he had purple heart in Vietnam, so he would have this in court. He would have these dramatic statements. I'm having a real bad shrapnel day because I have shrapnel logged in my thighs and my groin. I'm not having a great day today. He claimed that he was involved in covert operations for the CIA in Southeast Asia, including making delivery in Africa. He had a master's degree in psychology, worked at this prestigious law firm and Caltech. He went to school at Caltech and then Loyola Law School. He served in the Navy Reserves. All false lies, exactly. Now, the problem with Judge Cohenberg was that when he was being investigated by the board, the judicial board in California, he lied under oath. I mean, how do you lie under oath when you are a judge and a lawyer? Was that under his control? I mean, he knew he shouldn't lie under oath, but he did. So he was seen by Dr. Ford, who's a really eminent psychiatrist in this area of pathological lying. He served as an expert witness in his case. And Dr. Ford said that Judge Cohenberg was suffering from pseudologia fantastica, which he described as storytelling that often has a sort of matrix of fantasy interwoven with some facts. Dr. Ford also said that Judge Cohenberg did not have any underlying major psychiatric disorder, that this was the disorder he had. The disorder was called pseudologia fantastica. He claimed that the disorder was treatable and so on. I don't know where that came from, but that's what he said. But the important thing to note here, which is why I underlined it, is that he said that Judge Cohenberg did not have any underlying psychiatric disorder. The third person, maybe the last, I have a lot, but I'm going to stop here after this guy. You guys know this guy? You would know him right after Jeffrey Archer. He's a really prominent novelist, playwright, politician, actor, athlete, and liar. Former deputy chairman of Conservative Party, member of the House of Lords, contested for the mayor of London. Now, here's how people describe him, his colleagues. When you bump into Jeffrey, it's impossible to know which Jeffrey you are dealing with, the one who lies, the one with fabled gift for inaccurate per se, or the one who tells you what you want to hear. Another colleague, his life was a tapestry of fabrications, multiple mendacities, large and small, too numerous to list. But which one do I like the most? The comment from his wife. That's the one I like the most. She says that her husband has a gift for inaccurate per se. Anyway, he ended up being jailed for two years for perjury, which is lying under oath in court, and for perverting the course of justice. By the way, I'm using lying very casually here, and I said, you know, what am I doing in a room full of liars? Let me tell you, there are some areas in this country I dare not say that, because to be called a liar is the worst thing you can describe to somebody, and, you know, people have lost their lives, because all I have is my name, and now you say I'm a liar? That's it. Meet me out there. But it's a really big deal to be called a liar. So now pathological lying is not new in the literature. Let me tell you, it's been going on for over a century, even more than that. There's been many names that have been used to describe it through the years. Pathological lying, mendacity, pseudology, fantastica, and fantastica, depending on which part of the world you are in, compulsive lying, morbid lying, habitual lying, and so on and so forth. It's not clear if all of them describe exactly the same thing, but they are so similar in what people describe that they are used interchangeably. But the actual real definition and so on of pathological lying was first described by Dr. Delbruck, who was a German physician in 1891, and what happened was he said that five of his patients told lies that were so abnormal and out of proportion that they could not be normal. Now, they deserved a special category. This type of lies were so narrow and unusual that they really needed to have a special category. So he called them, he now developed the term pseudologia fantastica to refer to this type of lies. As I said, a lot of people have done a lot of work in this area, but I want to credit Healy and Healy, who really put together a fantastic compendium of all the work that had been done on pathological lying up until 1926. And then they defined it as falsification entirely disproportionate to any end in view, may be extensive, very complicated, manifesting over a period of years or even a lifetime in the absence, this is an important word, in the absence of definite insanity, feeble-mindedness, or epilepsy. So they are saying that this category of lies are extensive, they are complicated, they're even a lifetime of lying, but they are making a stand that there is really no observable underlying psychiatric disorder responsible for these lies. Now, they said that they observed that the utterance of lies comes just as quickly and naturally as speaking truth comes to everybody else. It's just the same to them. Well, some other researcher then had a slightly different view, says that all those whose lying is seemingly purposeless, so the lying is purposeless, and who by virtue of obvious mental disease. So this individual is saying, yes, I don't agree that there is no mental disease, I think there must be some underlying reason why people are lying like this, and it has to be something related to a psychopathic personality disorder that allows people to lose the ability to stick to the truth. There has to be something going on. When we looked at this, we reviewed all the literature regarding pathological lying in 2005, we decided to come up with a working diagnosis, which is excessive lying for no apparent purpose, easily verifiable to be untrue, maybe elaborate, fantastic, or dazzling, may last for years, even a lifetime, such that it becomes a lifestyle. The funny thing is, people might actually lie in a way that damages them, so it can be damaging to the liar as well. So if you break it down some, people always say, it's just important to note that pathological lying is not defined by the magnitude of the lies. The pathological lying as we know it, or as we are describing it in psychiatric literature, is not defined by the frequency of the lies alone, nor is it defined by the callousness or the consequences of the lie. Now, in regular discussion, you hear people say, oh, that's a pathological liar, and usually in regular discussion, out there in the public, what people mean is one of these things, either that your lies are too bad, or you're terrible, you're wicked, you're whatever. Those are things people mean when they say, oh, that's a pathological liar. But that's not what we mean when we say pathological liar in psychiatry. It's exactly what I've just described before, without all of this, or not necessarily this alone. So, after also having reviewed the literature, and gotten into the fights between, is there a mental illness or mental defect or disease that is underlying this condition, or is it primary? We decided that there were two particularly, potentially different categories of pathological lying. That there are those for whom pathological lying is primary. You can't find any other psychiatric disorder underneath. And then there are those for whom it's likely that there might be some psychiatric disorder or medical problems that might be responsible for some of this lying behavior. We can get into some of the reasons for that in a minute. But I want to point out the most recent definition by our psychology colleagues who wrote this fantastic book in 2022 called Pathological Lying Theory, Research and Practice, Curtis and Hart. Their definition, again, they did the same thing we've all done, only longer time now, since it's 2020, and ours was in 2005. But they did a complete review of the literature again. There's been a lot of work done since we wrote ours in 2005. And it defined pathological lying as a persistent, pervasive, and often impulsive pattern of excessive lying behavior leading to clinically significant impairment of functioning in social, occupational, or other areas of functioning, causing marked distress, and posing a risk to the self or others occurring for longer than a six-month period. All right. The main controversy that has dogged this condition throughout the years is do pathological liars recognize their lies as false, number one? Number two, do they have the ability to control their lying behavior? Now, I can tell you that all the prominent psychiatrists of the day have weighed in on this discussion, whether it's Schneider, Blalock, Jaspers, Fisher, a lot more individuals have weighed in on this particular question of recognizing whether you know that you're lying, or if you know, do you have the ability to control your lies? And so the two groups now fell into different areas. The group that says, I don't think these guys know that they're lying. I think this is loss of reality testing. I think they have no control. They have theories that support them. They are saying that at the final evolution of a lie, it takes on a delusional proportion because it has the worth of a real experience to the person. It becomes almost so real to them that it becomes a delusional experience. Others say that because the pathological liar really believes in what they are saying, seriously, that that has become a wish psychosis. It might have started off as some kind of a wish, but because they believe it so strongly, it's become a wish psychosis. Others say because the lies are so impulsive that they seize the liar suddenly, you know, that's the language they use. They seize the liar suddenly. They are so impulsive, it means the liar must not have control of these lies if they are so impulsive and they seize you suddenly. Others say that these type of lies are different qualitatively and quantitatively from ordinary lies. They leave the ground of reality very readily. After a while, the lies actually win power over the person so that he has lost mastery of himself or lost mastery of his lies. The lies have taken over. These individuals have termed it systematized delirium because the new I, which is a new lying person, has overwhelmed the normal person. Theories. They say that these lies are not real lies because the verbalizations are not consciously engendered and the goal is not consciously recognized. Like, what is the goal? They don't really consciously know where they are going. On the other hand, individuals who say absolutely not, there's no loss of reality testing in these individuals. They know exactly what they are doing. These are fantasy lies that guys are presenting. They are just daydreams presented as reality. The lie itself is the gratification the person wants, internal satisfaction for whatever reason. But this is fantasy, daydream, reflected as reality by the liar. Others talk about double consciousness, which is the person who lies and the person who doesn't lie live side by side with each other. Sometimes they lie, sometimes they don't. But there are two forms of a person, but that doesn't mean that they don't know what they are doing. They clearly know what they are doing. The other argument for this notion of knowing what you are doing is that, unlike maybe a delusion, in this particular type of behavior, if you energetically confront the individual with their lying behavior, with evidence to the contrary of their lies, energetically, they might really admit to their lies. More likely, however, is that they will just move away and run away and not continue the discussion. But the fact that you can bring them to a level of realization makes people believe that there's no loss of reality testing. Another argument is that they have sound judgment in other areas. How can you have sound judgment in other areas and yet claim that you have some kind of loss of reality testing that makes you lie repeatedly? The fact that it's associated with some kind of crime, minimal crime like theft, swindling, forgery, and so on, makes people believe that this is just one additional element of a criminal behavior. And then finally, the same impulses to literary creation that allows people to build foundations of romances and novels, all those fantasies that some other group of people say that that's exactly the same thing that's happening in pathological line. Therefore, according to this group, they know exactly what they're doing. According to the other group, it's not clear. All right, the epidemiology of this condition is that it is really hard to do this type of research and grab people who you identify as liars and then have them do this. But Healy and Healy in 1926 had 1,000 juvenile offenders, juvenile offenders, which already is a problem because these are already juvenile offenders. They already have committed crimes. Anyway, based on looking at those juvenile offenders, they decided that the prevalence was about 1% in the population. Dr. Ford looked at 72 other cases and came up with other epidemiological findings that the age of onset is around age 16. Everyone, I think, believes that the age of onset is in childhood or teenage years and so on and so forth. But the age of presentation, according to Dr. Ford, is 22. Sex ratio is equal. IQ, more verbal IQ than performance IQ. Now, there's this thing that was also a finding that 40% have an associated CNS abnormalities like epilepsy, abnormal EEG, head trauma, CNS infection, and so on. MRI findings show abnormal white matter changes. There's more white matter in the prefrontal region than gray matter, and people are trying to make all kinds of associations of what that means. Nobody knows what they mean. But people say, well, if you have more white matter, it means you have more fluidity with your speech and you can be more facile and so on and so forth. But these are all theories. Now, let's talk differential diagnosis. The first differential diagnosis is they must be malignant, right? Malignant is the intentional production of psychological or physical symptoms motivated by an external incentive. So there's a secondary gain, which either to obtain financial reward, obtain, you know, or avoid military service, avoid going into prison, avoid criminal events, all kinds of things. So it's either you are trying to obtain financial reward, obtain sick leave, you know, those kinds of things, or you're trying to avoid punishment of some kind. There's always an incentive for which you are doing that in malingering. Whereas in confabulation, which is falsification of memory occurring in clear consciousness in association with an organically derived amnesia. So there's an organic problem in the brain that has led to this memory lapses, and the confabulator uses material to plug the memory gaps. The confabulated material is used to plug the memory gaps. But there's also a difference in the type of memory changes is mostly affecting recent memory. You know, long-term memory is maintained, everything's fine. The pathological liar does not have any organically derived amnesia. They're not trying to block memory gaps with confabulated material. But it's clearly a differential in this condition. Another differential is Ganser syndrome, which really is approximate answers. I think everyone knows that this is a really fun condition to learn in school, where people just give, they know, you know that they know the answer because they're giving you just exactly approximate answer. How many legs does a chair have? Well, three. What about a dog? Three, or two, or five. You know, what's in the wind? You know, it's bang in the middle of summer and they just use the other one. So you can approximate answers. But also, the other thing that happens in Ganser syndrome is there's clouding of consciousness. There is some kind of hallucinatory signs and so on and so forth that do not exist in pathological liars. So just the fact that the approximate answers is too specific, that's not what we just described with pathological liars, with the elaborate lies and so on and so forth. Factitious disorder is also intentional production of psychological or physical symptoms only in this particular instance is to assume a sick role. We're gonna get back to talking a lot about factitious disorder later because I want to contrast and compare factitious disorder and the pathological liar in more depth later in trying to convince you all that pathological liar should have his own diagnostic. Now, a differential diagnosis is also delusions because as you know, some people have said that the liars believe their lies so much that it becomes almost a delusion. Well, a delusion is a fixed-force belief that is held so tightly despite incontrovertible evidence to the contrary. No matter what you show them, they will hold their lies completely and it is out of context with their cultural, religious background or any other person who works with them. They just hold it despite incontrovertible evidence. That's not the same with pathological liar. Now, there are some personality disorders that might be a little dodgy here, like borderline personality disorder. Individuals with borderline personality disorder hold contradicting views of themselves at different times and sometimes you have short periods of loss of reality testing. It can really be confusing when somebody presents that way and might be confusing sometimes with pathological liar. But the other features of borderline personality disorder will slap you in the face and you will know that this is not pathological liar. Likewise, antisocial personality disorder, everyone knows they lie for a gain, but there are some times they lie and you're just not sure why this antisocial guy is lying like this. So those times might be confusing, but again, the overall picture of antisocial personality disorder with careless disregard for safety and all those different other symptoms will also slap you in the face and you'll know that this is antisocial personality disorder and it's not pathological lying. Histrionic, narcissistic, the same thing. Histrionic personality disorder is all about me, just dramatic presentations that just for unconditional regard from you. They can do things that will make you wonder if why are they doing this? It becomes the question. The one question you always have to understand with pathological lying is why are they doing that? Because you can't really understand why somebody would lie to the extent of which they are lying. But in histrionic personality disorder or even narcissistic personality disorder, the core symptoms of these disorders will also slap you in the face because these are really great, huge, problematic personality disorders. So when you summarize the differential diagnosis, it is clear that there is no pathological lying really associated with malingering, confabulation or Ganser syndrome, but there's a question about the association of pathological lying with these other conditions, factitious disorder, borderline antisocial and so on. Now what about as a diagnosis? There are arguments for a primary pathological lying, as I said before. An example of this could be Professor Ellis that I just described, Judge Korenberg, people said they did not have any underlying psychiatric disorder, but they were also diagnosed, at least Judge Korenberg was formally diagnosed as suffering from a pseudology of fantastical pathological lying. In other words, pathological lying can exist primarily as a primary disorder. But going back to 1955, Cleckley, who's a really prominent psychiatrist of the day, described the case of a successful and respected man with a doctorate in physics whose stories were filled with exaggerations and falsifications, sometimes conscious or half conscious, but he did not have any psychopathic or any other signs of insanity, according to Dr. Cleckley. So he was describing the case of someone who Dr. Cleckley believed, we, looking at it, believe was a primary pathological lying disorder. There's also something in the literature by an individual known as Casey and his colleagues, they describe conditions pseudology are due, pseudology are due, which is akin to foliaire are due, but in this particular instance, the primary individual with the problem has pseudology, has pseudologia fantastica, and then their companion, who is the less dominant, begins to exhibit the same behavior as well. So these are reasons to consider pathological lying as something that can have a primary diagnosis. It can also be secondary. That's the question is, can it be secondary to disorder conditions? We mentioned some CNS problems that were associated with it. We don't know if they are causative or if they are associations or just incidental findings. They talk about the pathological liar is compelled to lie. Well, is this a compulsion? Is this a form of OCD? And is the fact that pathological lies are impulsive and they seize the liar suddenly? Well, is this an impulse control disorder? So questions you ask about this. Is this part of some personality disorders? In one area, when I gave this talk to a group of residents, one of them asked me if this was an addiction. And I thought about it for a long time. I don't know the answer to that, but it does seem like maybe there's something it serves to someone, it gets to a point where it might become, I can see how somebody might wonder whether there was an addictive quality to this. We talked about some prefrontal white matter changes. We don't know if this is a variant of some kind of psychotic disorder. So at least the question of is it secondary should stay somewhere there. Can it be a secondary disorder to something? People have certainly said it was secondary to factitious. It was a symptom of factitious disorder in some area. But we'll get to that in a minute. Now, what are the implications of having pathological lying? You can see that it is an impairment in social, occupational, and other areas of functioning. Relationship issues. Can you imagine your spouse being a pathological liar? Every relationship is built on trust. You can't have any trust. There's credibility problems. It's very, very difficult for such relationships to stand strong, ultimately end up breaking up. Sometimes pathological liars are forced to come in to treatment because their spouse is saying, you know what, I'm gonna leave. I can't handle this anymore. Social interactions. Who wants to be associated with a pathological liar? Negative attitudes. If you see someone who's a liar, I just told you before, the worst thing you can call somebody is that they're a liar. And then you associate with them and they're your friend. So everyone can say, who's the liar here? So people avoid them. There are also job issues. You become a brunt of jokes. You become a brunt of jokes at your workplace. Oh yeah, that's what Charles says all the time. And then of course you can get in trouble as well when you lie about really important things. And of course loss of job has also been a real problem in situations like this. It can get you in trouble with the law as George Kurenberg, as all the other individuals have gotten in trouble sometimes as a result of pathological lying. In fact, the case that got me interested in this was a case of someone who was going through a legal process and the attorney was baffled. I was a forensic psychiatric fellow at the time. The attorney was baffled because the attorney could not help this individual go through the trial. Was wondering whether the individual was fit to plead or competent to stand trial because he couldn't assist them. Every day there's a new story and there's a reason why there's something else and so on. So it became a real serious problem for the attorney. That was why we were invited to participate in that. What about treatment issues? First you have to make sure you do an elaborate workup of course as always. But the workup must include a lot of collateral information. A lot of history about past legal history and all of that. The picture there is my picture. Forget that it's white, it's me. Pulling out my hair thinking, what am I gonna do with this guy? And I don't have hair anymore, I'm sorry. But there's a question of the role of psychological testing. Psychological testing really is just to help you identify personality issues or any other type of underlying psychopathy and so on, or psychopathology. But it really is not that helpful in pathological line. The biggest issue in treatment is counter-transference. You are there in psychotherapy, person comes and they're lying to you all the time. It's very difficult to love them. It's very difficult to have unconditional love and it's very difficult to have unconditional positive regard for your patients which is what our ethics say we should do. And somebody is like that. Therapy is almost like, some of the therapies described it as shooting in the dark because you just don't know where they are going with any of their stories. Now some of the therapeutic interventions that have been helpful are mostly in the past. In the past it was all psychodynamic psychotherapy and nobody really knew whether they were helpful or not. Although there were some statements that some people improved and others didn't but it was very difficult to get data on that. But now I think cognitive behavioral therapy, some other forms of behavioral therapy, habit reversal therapy are all things that have been tried. I'm not sure if they've been as effective or there's enough data to show that they've been effective. But I know that a lot of our psychology colleagues are really working in this area. I wondered about the role of medications in the article I wrote in 2008. And I wondered about that because if we say that there's a possibility of impulsivity to the lies or compulsion to the lies or addiction to the lies, might we not try some of the medications we use for impulse control disorder or OCD or even addictions? Might we not try them and see? Those are all speculations as to treatment. Now the forensic area I just mentioned, you wonder whether somebody is competent to stand trial. Competency to stand trial is, do you understand how the court works? Do you understand all the different players in court? Are you able to assist your attorney in resolving your case? Well, if you're lying all the time, you might have, we've already talked about perjury, which is lying under oath. The question that I think most people would really frown at you is if you say that these individuals are not guilty by reason of insanity for the crimes they commit. Even though the idea around not guilty is that you have a severe mental illness, we're saying that these individuals do not have a severe mental illness. The question about treatability becomes really important in the legal arena because in order for you to have some kind of mitigation in court, you should be able to tell the attorneys, the judge, that well, if they get some treatment, they'll be better. So these behaviors are not gonna happen again. But if there's no treatment, it's really hard to argue for mitigation. All right, let's switch over a little bit to fictitious disorder and see how they look, how different they are, how similar they are. Fictitious disorder was described in 1951 by Richard Oshoi, a British hematologist, who also coined the term myxedema madness in his review of hypothyroidism. So here's his quotation. "'Like the famous Baron von Munchausen, the person affected have always traveled widely, and their stories, like those attributed to Baron Munchausen, are both dramatic and untruthful.' Hence, he recommended the term Munchausen syndrome. In addition to frequent lying, patients with Munchausen syndrome characteristically travel from hospital to hospital across regions, states, and even countries. They're admitted to the hospital with apparent acute illness supported by a plausible and dramatic history, largely made up of falsehoods. Most remarkable feature of this 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." You see how similar these things are now? Okay, I'm gonna get that, so I still keep talking. Diagnostic criteria for factitious disorder begins with an intentional, conscious production of psychological or physical signs and symptoms. Now, DSM-III, all the way from DSM-III to DSM-IV-TR, state that the best-studied form of factitious disorder is called the Munchausen syndrome. That individuals with factitious disorder with predominantly physical symptoms may indulge in uncontrollable pathologic lying in a manner intriguing to the listener about any aspects of their history or symptoms. So now they are tying in to the Lodge of Fantastica in the DSM. And DSM-III-R says this, in describing factitious disorder, says that compulsive inequality could not be, their lies could not be relinquished despite known dangers or adverse consequences. So they are wondering if there was a loss of control in these individuals. DSM-IV-TR recognizes to the Lodge of Fantastica, this is where a real clear connection in DSM, recognizes to the Lodge of Fantastica as a common feature of factitious disorder, but one that is not essential for the diagnosis. It's a feature, but not essential. Now, this particular connection was dropped in DSM-V, but was it really? DSM-V-TR says factitious disorder is falsification of physical or psychological signs or symptoms or induction of injury or disease associated with identified deception. The deceptive behavior is evident even in the absence of external reward. So it dropped the word for the Lodge of Fantastica, but they seem to be referring to it there in the DSM-V. All right. Question here is, did Baron von Munchausen really have Munchausen's disease? Did he have factitious disorder? There's absolutely no evidence in the history so far that the Baron ever assumed a sick role. There's nothing that showed he assumed a sick role. All we know was that he had fantastic and dramatic stories. I mean, the literature is filled with all kinds of dramatic stories of what he was doing that seemed really illogical, some of them, but fantastic stories. So I submit to you all that what the Baron actually had was Pseudologia Fantastica and not Munchausen syndrome, because there was really no connection to the sick role. Now, what are the commonalities between those two? We talked about frequent lies, deceptiveness for no apparent purpose or gain, where there appears to be a purpose such as to assume a sick role in a factitious disorder. The cost appears to outweigh by far the apparent gain. The lies can be self-destructive. By the way, that's also true for pathological lying, where there appears to be an apparent gain for this pathological lie, the cost appears to be really outweigh by far the potential gain that you have in the pathological lie. Negative consequences or personal consequences do not deter the behavior in any way. The lies and deceptive behaviors are senseless, maybe fantastic or even grandiose, told for a lifetime, and are difficult to give up in both conditions. When vigorously challenged, they might slightly alter their lives or run away. The factitious disorder individual will create a half, throw things in the air and run away and go to the next hospital and do the same thing again once you confront them. And of course, it is questionable, always questionable in both conditions whether the individual has ability to control their behavior. But there are clear distinctions. In pathological lying, the lies are broad and varied with no consistent singular focus. So everything, you can lie about anything. Whereas in factitious disorder, the lies seem to be more narrow, seem to be focused around the assumption of a sick role in one psychological or physiological sick role. And this is a comment that even in factitious disorder situations where elaborate lying is not apparent, the core element of factitious disorder which are deceptiveness, senselessness, damage to self, no apparent gain, apparent lack of ability to control behavior and travel rather than admit deceptiveness are all recognizable elements of pathological lying. Therefore, if this were a tree that had both pathological lying and factitious disorder, I would say that pathological lying is a tree trunk and factitious disorder is the branch. Because pathological lying is broader, the same symptoms about everything, whereas factitious disorder has come down to a really narrow focus. I'm going to use a case example to describe some of this. So this is a case that was reported in the Fort Worth Star-Telegram in Texas in 2015 of a woman whose name is Ms. Yabara. She's a former chemist and a mother of three children. The title, by the way, of the newspaper article was Malcherson Mom. She was arrested in 2009 and subsequently sentenced to prison for 10 years for a charge of serious bodily injury to a child. She subjected her second daughter to 30 to 40 surgical and medical interventions from which the second daughter almost died. She caused the child to have surgically inserted gastrotomy tube for feeding as treatment for reported swallowing dysfunction. She worked as a chemist, by the way, so she injected pathogen she stole from her lab to cause her daughter grave illnesses. She altered her daughter's sweat glands, leading to a diagnosis of cystic fibrosis. She drained her daughter's blood, causing severe anemia. Her daughter went into life-threatening anaphylactic shock when ion dextrin was infused to treat the anemia. All right, so those are all the examples of a factitious disorder. This was how people got to know her. People saw this woman who looked really, looked pitiful with daughters who were very sickly, one who had cystic fibrosis. She herself had shaved her head. She looked really, you know, pitiful in that instance. But when you now explore her history further, you go back to her history. She has a long-standing history of frequent lying behavior for no apparent reason. Right after her marriage in 1998, she told her husband she was taking classes for a PhD. She left home for classes on Tuesdays and Thursday nights for one year, after which she announced that she had obtained her PhD. Her husband was a little dubious about this, he's like, really? But he wanted to support her, so he just went along with it. She printed PhD on everything, including business cards and her email address. In 2001, she informed the family that she had just been diagnosed with bone cancer, and for the next eight years, her cancer rules grew even more elaborate. She would claim it had spread to her brain, her lungs, destroyed her hearing, prompting her to learn sign language, which she did, and later reportedly get a cochlear implant. She claimed she beat the cancer twice, and then she moved to Alabama, leaving her family to move to Alabama for eight months for treatment she could not get anywhere for this cancer. While reportedly undergoing the chemotherapy, she announced to her family she was pregnant with twins, and then she subsequently began to wear maternity clothes, named her unborn twin girls. One day, she suddenly informed the family that she had miscarried them at five months due to complications of her cancer treatment. By the way, she was not receiving any cancer treatment, there was no cancer diagnosis, there was nothing going on here. Then she held a mini funeral for them, claimed she had the twins cremated, after which she kept a sealed urn of their ashes on their fireplace mantel. 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 twin girls she reportedly miscarried. So, all right. Her lies were numerous, were unfounded, were unlogical. They preceded her factitious disorder presentation. Later, some of her lies provided an opportunity for her to assume a sick role, or to be the center of medical attention, but many of her other lies did not have any of such connections. So it's factitious disorder imposed first on herself and then on her child. In all situations, the negative consequences of our behavior far outweighed whatever benefit or goal that could be gleaned from it. Her lies continued in prison. After she was sent to prison for 10 years, a reporter, journalist, went to interview her there and just continued her lies as if nothing happened, despite contrary evidence. But factitious disorder is a DSM diagnosis. Pathological lying is not. Why is that so? Because patients with factitious disorder cannot be ignored. There's absolutely no way you can ignore them. They present a significant distress to healthcare systems. They hold the system hostage, really. Patients are most likely to present in psychiatry, neurology, emergency medicine, internal medicine, and they will be seen, and you would know. They will capsize whoever they are. They will cause trouble. So you need to know that there's something going on. They consume an exhausting amount of staff time and drain physical and emotional reserves of clinicians, also drain financial resources of systems taking care of them. In other words, they are really demanding you to diagnose them. You cannot not diagnose these people. So they have a diagnosis. But it's really important for pathological disorder, pathological lying, or pseudologia fantastica, to also have a DSM diagnosis, because that's going to encourage even more research. By the way, there's been a lot of research, but it will encourage more systematic research in this area. It will decrease misdiagnosis, improve knowledge that allows people to be able to finally name what behaviors they see with their patients, because a lot of people are really... This is not a hidden symptom. It's not a hidden phenomenon. Most people who practice in this area will see them. In fact, I can't tell you how many correspondents I get from all over the world, people telling me about their brother, sister, uncle, aunt. So it's not hidden. But the fact is, when they come to care, we diagnose them with something else. And that social personality disorder, borderline, we're not giving them the right diagnosis that they deserve. And that is a real problem. So my colleagues, our psychology colleagues I mentioned earlier, suggested a DSM diagnostic criteria, persistent and pervasive pattern of excessive lying behavior occurring for longer than six months. The symptoms cause clinically significant impairment in social, occupational, and other areas of functioning, which I already mentioned to you. The behavior also causes clinical distress for the individuals concerned. It's not attributable to any physiological effects of substances or any other medical condition. And they are not better explained by any other medical or mental disorder. And then you can specify whether it's primary or secondary, or whether it's in fact pseudo logia fantastica, where the lies consist of extremely exaggerated series of life details and so on and so forth. I think that this is a really, I think this is a great step in the right direction. And I think this captures a lot of what we've been talking about with these individuals. And it's really hard to argue that this criteria, this diagnostic criteria, is inappropriate or false. But let's go into conclusions now. 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, the cause to the person, the patient, or to the pathological liar, which is painful and stressful medical surgical procedures, loss of job, criminal convictions, far outweigh the apparent gain of the lies or deceptive behaviors. I can't imagine George Kohenberg's lies being more important than the fact that he lost his judgeship. I just can't imagine that. And for what? And the same with, you know, Professor Ellis and all the other individuals who've been problems or had trouble with this. The lies can be self-destructive, but negative personal consequences are not a deterrent. The lies and deceptive behaviors are senseless, may be fantastic or even grandiose, stood for a lifetime, and are difficult to give up. When vigorously challenged, they may slightly alter their lies or run away. Now while in pathological lying, the lies are broad and varied and with no consistent focus or singular focus, factitious disorder, on the other hand, they are more consistently focused around psychological and physiological or physical symptoms. So I end with this quote by a retired Navy captain, that some people have lived their falsehoods so long that they could pass lie detector tests about their stories. Thank you so much for your attention. So I open it up to questions, please. You can speak on the microphone, if you have any questions or comments. Let's go to the microphone. About this mind-chosen mom, how do we know if it's not delusional disorder? I think that's an interesting question. One of the things I don't know is, obviously I don't have access to her medical records. All I have are reports from her family and reports from the journalists. It doesn't follow the pattern of a delusional disorder, because if you look at it now, you claim you're pregnant, and then five months later you say you've lost them. In what way, how would that be elaborated in a delusional disorder? You know what I mean? Or you leave your home for eight months to go receive treatment, and then come back. How would that be? It doesn't follow the usual pattern of what you would call a delusional disorder, or even the idea of getting a PhD in one year. You tell people, I'm taking classes, and then you say you've gotten a PhD. Again, it doesn't follow the pattern of what you would call a delusional disorder completely. I acknowledge that I don't have all the records, and I don't know anything. It just doesn't follow that pattern. It's more clearly, at least the factitious disorder element is so clear. She was fired from her job, because people began to get sick at her job. She was putting things in people's drink. So, it just seems to be in the pattern of what we know. Thanks. If someone didn't start out as a pathological liar, and say they're at a job that compels them to lie, because they threaten that if you don't lie, you're going to get fired, or you're held by a captor, and they say you need to lie, because your life depends upon it. If you get them out of that situation, can you correct it where they're not pathological liars anymore, and they're actually become, like us, just tell a lie here or there? First of all, let me say thank you for acknowledging that we all tell a lie. Now and again. That's actually normal. It's just, and there are so many reasons why we can tell a lie. I went to one conference where the first question I asked people, if anyone lied, they said no. When somebody got really upset, I never lie. I said, what are you going to tell your wife in the morning when she says, honey, how do I look? But you need to change your question, because you said lie in the last day or two. Yeah. Every day. If it was beyond that. We lie every day. I didn't have to raise my hand. That's just a joke. In terms of pathological lying, it's so broad, and so it's not just related to the job. I mean, if you're lying only in one area at the job, it's probably not pathological lying, and it's about anything. It can do anything and everything and everywhere. So it doesn't have any consistent focus, right? It doesn't have a particular, the only place where there's a consistent focus is when it's factitious disorder, and its focus is really to obtain a sick role. But in pathological lying, it's very difficult to know why. And so if you remove somebody from somewhere, you haven't really removed the lying behavior. You just continue to lie about other things. So I don't know, until somebody is able to get a handle on this, it's always going to continue to be a problem. Thank you. You're welcome. Thank you, Charles. Great talk. Really interesting, and I have to say that in 35 plus years of practice, the two most interesting patients I saw were in these categories. One was factitious disorder, one was clearly pathological lying. And I agree with you. I think the diagnosis is important, because then I would have had a diagnosis to give the young man with pathological lying when I saw him in the ER. But my question for you as a forensic psychiatrist is, how would the presence of this diagnosis impact your doing evaluations on patients with this disorder? What difference would it make in those assessments? That's a great question. Well, forensic assessments are by nature extremely broad, right? So you would not only talk to the person, you would talk to everyone that's connected to them, that's known them, that's relevant, right? Relevant people around them, you would talk to them. You talk to work colleagues, you talk to high school friends if you know them. You talk to so many people, so you get a real picture of who you are dealing with. You gather as many materials, collateral documents you can, related to them, whether they are medical or school records or anything, work performance records, all of it help you put together a picture of a person. So you begin to see who they are beyond what they tell you, beyond what you see in front of you. So in terms of assessment, of course you do psychological testing to just add to it, make sure that there's nothing off from a psychological testing perspective. You put this together in a real long story report. The problem in forensics is really, I can come back and say that this individual, based on all of these assessments through all these different areas, present in this format. The problem is how does that help them in court? And that's a really difficult area because the first big challenge is whether or not they can really be competent to stand trial. That's the first real serious issue because if you can't, if the attorney cannot be sure of what you're saying from day to day, and you can't assist them in assisting you, and the stories change all the time, and they're elaborated in different ways, it's very difficult for them to support you in court. So that's really the biggest issue that you have to overcome. Many times people might just do a plea bargain and get out of it because it's really, it's very difficult to go through a court process. And the risk of perjury is really huge because you might find yourself lying in court. So it's very difficult in the forensic arena. I think that the only thing that's going to help is to be able to let the court have a narrative that describes the struggle that this individual is having throughout their lives, that describes how this has affected them socially, occupationally, relationally, all through their lives, that helps them understand that perhaps they don't really have complete control of this, perhaps. That is making them go through these difficult areas and hope that the court might have some mitigation in terms of looking at the kind of sentence that it can give them. But I did mention very quickly before about treatability. It's really important for something to be treatable. So if there's enough research that begins to show that some of them can be treated, then we can say that with confidence to the court, and that will help the court also think about ways to mitigate their sentence. But if a condition is not treatable and it causes dangerous behaviours, it's very difficult to know how to help you navigate the legal system. Thank you. Thanks for the talk. My question is around your view of the entity of clinical distress as part of the diagnosis. I've been sort of struck by the sort of indifference or whack-a-mole approach to life that some of these patients seem to have. That you have what? Like a whack-a-mole response to when they're caught out with their lives, and there's sort of indifference to being caught out at times. I'm wondering what your view is of clinical distress. The clinical distress comes through the consequences that they experience, whether it's loss of job, whether it's loss of relationships, whether it's – I had a case of a young man who was now spending 10th year in college. Every year he would tell his parents that his graduation is coming. Parents are scattered all over the country, and in fact internationally. They will all gather, and then the day or two before, there'll be a story as to why this graduation is being postponed over, and so it really became very difficult, and you can see the pressure on the person became, it became very distressing for him after a while, because he was still receiving money from his parents to go to school, and yet he hasn't really gone to school, and yet he's been lying all this time, and the importance of that to his grandmother, who was still living, was really driving him aground. So there can be significant, the distress comes with the effect it has on others, and that is now blowing back on you, or the effect it has on your ability to provide for yourself. I don't know if I've answered your question, if not, please clarify it a little bit more. I guess my curiosity is when we come across these people before life has fallen apart, would you still make a diagnosis of pathological lying if the rest was present? Well, I think it's very difficult for somebody to have lied consistently for six months or one year, and some things not really happening in their life. So it's a question of asking them, how has this affected your life? What is it that you have lost as a result of this? Even, because by the time you discover them, they've been lying for years, right? So it's really, it's really trying to find out from them in what other areas of their life has this really affected them? Has it stopped them from being all they could be in life, like the job that they could have, and what does that mean for you? And so by the time you begin to tease out how this has affected them, you begin to get to the element of distress, because it will tell you how they feel about it. Thank you. You're welcome. Thank you. Great presentation, Doc. Thank you. Wonderful. Thank you. You know, Harvey Cleckley, the famous psychiatrist who wrote the book, The Mask of Sanity. Yes. He describes the psychopathic personality in there. Yes, he does. He interviewed a lot of patients at the jail in Atlanta. Could you please comment on that as to how that psychopathic personality would fit in in the pathological liar? It's interesting because one of the examples I gave was from Cleckley. So he saw somebody who had this type of behavior, who had a doctorate in physics, but was a consistent, a frequent, lifelong pathological liar, just a liar. And he made clear to note that there was no psychopathy. There was nothing, you know, insane about this individual. And so he himself was baffled by this guy, because he did not meet the picture of psychopathy that he had. So the idea of this particular condition being part of a psychopathic personality disorder is not new as well, because my first slide about Selling and his colleagues said there has to be a psychopathic personality of some kind associated with it. That's his view, but that view is not universal. A lot of people don't see anything that has to be psychopathy. So that's the question, right? Are there people for whom there's some kind of personality disorder that might be associated with the behavior? Probably. Are there people for whom there's nothing at all? Probably as well. So that's where we are at this point. That's the state of the science. I suggest everybody should read that book. It's hard to find it now. Yes, yes. It's out of print. You're right. I had, when I was finishing my training back in the 80s, the library was throwing away books. Yes, and they threw it away? No, I found that book, and I have it. So it's a very old edition. It's fantastic. It is a phenomenal book. Second question I have, I won't take long. I work in the jail system part-time, and I often see patients on the jail mental health unit. I treat them. I treat the inmates, and there are, they're in the jail for like a year, year and a half, diagnosed with all kinds of conditions, chronic psychiatric illnesses. What are you waiting for? I'm getting an NGRI evaluation. That's what they say, and two or three psychiatrists see, and nobody seems to come to a conclusion whether they are NGRI or not. You know, is that becoming a problem for forensic psychiatry? Actually, so this is a completely different topic. NGRI is not really an easy defense. Only about one percent succeed, so it's very, it's not a problem. People know exactly what the criteria are. I don't think it's a problem. I think there are people who might want to be NGRI. The onus is on the psychiatrist to determine whether their presentation meets that, so it's not a problem as far as problem goes in forensic psychiatry. But these are malingering from... Yes, so then you have to do a lot of work. You have to do, as long as you do the comprehensive assessment that we do, every forensic work you have to rule out malingering. Every forensic work, especially criminal forensic work. That word is being used very loosely in jail system. This patient is malingering. It's used loosely, but it's also a word that you have to use with a lot of care, because you don't want to call someone malingering. It's like calling someone a liar. It really is a huge deal. You have to be very careful. When we train fellows, we say try to find words like, you know, grossly or misstatements or some other kind of terms that show that it's probably not correct. By the time you use malingering, you better be sure that you are clear in everything you've done that your diagnosis is malingering. Objectively. Yes, exactly. Thank you. You're welcome. Thanks. Thank you for your presentation. A three-part question. I'm wondering about the baseline rate of lying. So as a psychoanalyst, I would argue that the unconscious allows us to lie to ourselves every day. So if you're trying to ask what you're lying about, wouldn't you need to ask other people who know that person sometimes to even assess a baseline rate of lying? Because I remember during the election, they said 20% of politicians baseline lie, all of them, even the good ones. So what's our baseline rate when we do studies like this to say, where's the line of pathological? The second part is, are there cross-cultural studies on these diagnoses of lying? Because I would also argue that lying has become culturally syntonic for our culture right now based on a lot of things that go on in the world. And lastly, while you said this, you can actually diagnose this in children. So I can understand as a child psychiatrist that you can tell for adolescents, but how could you assess that in the pre-adolescent child? So if I'm seven, I say, mommy, I didn't do it. So I tell parents this all the time. When the child says, mommy, I didn't do it, I wouldn't go to, they're going to be a psychopath. I would think developmentally that is not inappropriate. So you scared me when you said, it may be true. How do you even assess in childhood what is really a lying that will become pathological? Yeah. Great question. I'll start with the last one. So pseudo-lying in children is normal. It's fantasy. Children use fantasy lies to navigate the reality of the world and so on and so forth. So that's normal. Some of the theories around pathological lying is that they are stuck. They are fixated at that childhood level of pseudo-lying and they've not navigated that. I question, I think the, when onset is around 16, so it's about teenage years more than child, you know, younger children. I know that there's literature that talked about people who are from, you know, four and so on up, but most people would say around the teenage years. And even then, lying behavior, lying generally is common in teenage years. And as you get older, and as you get older, you drop them, you know, you drop that. So the different, we don't make a very clear distinction between what we call pathological lying and what we call ordinary lying. Ordinary lying. Yes. Only in this culture can we have ordinary lying. Yes, yes, yes. Pathological lying is a very narrow form of lying, you know, which I defined earlier. Excessive lying for no apparent purpose or gain. Do we really know if this is a continuum though, or these distinct, like discontinuous categories for people? What do you mean? I'm saying, can we tell what ordinary liar will become a pathological liar? That's why, these are great questions. These are really good questions. I think that's why, if somebody, if somebody, the difference between a lie that somebody, everyone can see that what you're saying doesn't make sense, it's not clear, and your family members can see that this never happened and it doesn't make sense, to a lie where nobody's sure whether it is true or not is very clear. It's very difficult to know the base rates of what you're describing. That's really part of why we need to have a, that's why we need to have this as a diagnostic entity, so that we can actually engage in very serious research in the way you're looking at it, with clear parameters of research, including what kind of base rates are you using, and what parameters are you using to define one area or the other. So right now, definition is really descriptive, right? It's really trying to describe what we see as best we can, as opposed to the type of rigor that we might have to have with systematic studies. Thank you for your patience with my questions. No, I don't, I hope I answered them. I think you have great questions. I don't know that all of them have answers at this point. Well, you're saying that the latter point, that we don't have criteria, and it doesn't exist as a diagnosis per se, makes it impossible to ask the first, answer the first two questions. That's why we need to have it. Thank you so much. Thank you. So, thank you for your presentation, and I think you maybe answered a little bit of my question already in the past answer, but I was wondering, because you mentioned, or there seems like that pathological liars have like this new sense of self that they, so they didn't even show up if they, on a liar, or I would say on the lying test, that they seem to truly believe it. Do you have any, found any useful psychodynamic perspectives on the origins of how this new sense of self comes to be? Yeah, so you, one of your questions is whether there's a lie detector test. Does it reflect, is that one of your questions? The question was if you found any useful psychodynamic perspectives on how this. Psychodynamic perspective as to why people develop this. There are lots and lots of theories about it. Some have talked about a, an attempt to, to avoid the trauma of their life. Some have talked about an attempt to present themselves in a way they would like to be as, instead of what they are going through now as a defense mechanism. There's all kinds of theories around it and the psychodynamics, but I don't think there's any that is really sound. Now the reason I say that is a lot of psychologists and psychiatrists who have dealt in this area were, were working in the area when it was only psychotherapy and psychodynamic psychotherapy. So they had a lot of theories around what might be dynamic things going on in people's lives, but I don't think that they have coalesced really in any serious way to say that this must be. Because some of the individuals, when you look at their background, they actually didn't have any of those things in their history of their background that you, that you can say they were traumatized and they were trying to avoid this. Some of these prominent people who have become really world renowned, you look at their backgrounds, you don't see anything that you can state. So it becomes really a conundrum as to why is it that these individuals are doing this? So there are many dynamic theories, but I don't know that they are strong enough to be able to explain this in any rational way. Thank you. Welcome. Thank you for an interesting presentation. I was wondering if there are any unique psychological testing findings, either with projective testing or MMPI that help to differentiate this condition from say factitious disorder, malingering. It strikes me that if someone is lying all the time, you're going to get invalid testing frequently, but perhaps with projective testing there might be some unique pattern. I don't know. No, we've, I worked, our articles were written with a psychologist in our system and we tried to look into all of those things. And at the end of the day, psychological testing is just not helpful. Because of the invalidity? Yes. Yes. It doesn't tell us whether it is one thing or the other is invalid and it doesn't differentiate whether they say factitious disorder or pathological disorder. It doesn't really help. All it helps you is exclusion. Is there a personality disorder here? Is there something else going on? But projective testing doesn't really show any things that relate to psychosis or anything that points in that direction. So it's not been helpful at all. Yeah. The other thing I wondered about was whether there's any relationship between dissociative phenomenon and pathologic lying. That's a great question. I haven't seen anything that suggests that. I haven't seen anything that suggests that individuals appear to be in a dissociative state. Right. Like they've lost time and they're looking. I haven't seen anything that suggests that. But it does raise the question. I mean, it's an interesting question. I just haven't seen it yet. Okay. Thank you. Thank you. Thank you very much. Thank you so much for this talk. I understand there's still a lot left to know or to learn about this. But in your study, are there any risk factors that you have identified or any that you suspect in terms of heritability or environmental or other factors? Not yet. Certainly not from me. I haven't. Risk factors for developing pathological lying, you mean. I don't know that there's any that's listed anywhere that these are the potential risk factors to worry about. But I'm intrigued by that as well. It's something that I wonder myself, like what would make somebody or predispose them? And as you think about formulation, you think about predisposing factors for an illness. I don't know so much what the predisposing factors for pathological lying would be at this point. And I think part of it is driven by the fact that there's a question talked about associations. It's a question of organicity in some individuals. Would that predispose them? Is there something wrong with their CNS somewhere that predisposes someone to this type of behavior? Or is there a personality structure that predisposes someone? I mean, the associations with personality disorders like borderline, narcissistic, histrionic, and so on. Would they be predisposing factors? Would they be risk factors? I don't know for sure. At this point, we only know them as associations, but I don't know if they are risk factors. Thank you. You're welcome. Have there been any studies looking at families and parents of people who are pathological liars? Sometimes I see that with adolescents. The parent will be someone who distorts the truth, and then that becomes syntonic. So I wonder if there are any family studies to see how these disorders aggregate. I haven't seen any rigorous family studies that look at that. It's clear that certain things happen in families. Is it something you learn? Is it a learned behavior? Or is it an acquired behavior? Is it an innate behavior? That's clear, but I haven't seen any family studies that really demonstrates the incidence of this condition that it runs in families or anything like that. I haven't seen it yet. By the way, I think maybe you can help us do some of these studies. I'm serious. These are great questions. I think maybe... I've treated lots of adolescents with acting out. You see how these kinds of behaviors begin prominence, sort of like an early adolescence as they evolve. Yeah, but I think the great thing is that most people, by the time they become adults, at a certain level, would drop some of those behaviors, and it becomes only a really small number that would take any of these behaviors to a certain level in adulthood. But the questions you're asking are exactly the reasons for which I think we need to have some place that we can say we are looking into these conditions. We might start off with some criteria now, and as you know, with time, the criteria might change based on the findings that we get from research once there's enough opportunity to engage in it. But there has to be a starting point. I think the issue is really, is there enough in the literature right now for someone to be diagnosed with something that looks like pathological dying? Yes, there's enough in the literature. Certainly, if we can diagnose people with factitious disorder, we can diagnose people with pathological dying. And that would just provide a platform for real investigation of this condition, and also help decrease some of the difficulties some of our colleagues are having when people like this come to them, and you don't know what to tell them. And then you give them some misdiagnosis, and so on. But I do think that there's room for a lot of investigation, and some of what you've described today will be really important to look at. By the way, the idea of trying to get enough people for research, people to identify themselves as pathological lying, and their family identify them as pathological lying, and they come to your place for research, is a really tricky thing. But people are doing it, some. Well, thank you all so much. Thank you for having me.

pathological lying

Charles D. Kaye

pseudologia fantastica

Joseph Ellis

Patrick Cohenberg

Jeffrey Archer

malingering

factitious disorder

psychiatric practice

diagnostic entity

social impairments

psychiatric disorders