A Reverend’s tale: Too tragic to be true?

DIAGNOSIS: A rarely seen symptom

Reverend R meets the DSM-IV-TR criteria for factitious disorder (Table 2).¹ The presentation of a patient with this disorder may include:

• fabrication of subjective complaints
  
• self-inflicted conditions
  
• exaggeration or exacerbation of pre-existing conditions
  
• any combination of these.
  

In addition, we determine Reverend R has pseudologia fantastica, a rarely seen form of pathological lying characterized by telling elaborate lies that may have a kernel of truth (Table 3).² The syndrome often is associated with cognitive dysfunction, learning disabilities, factitious disorder, and childhood traumatic experiences.^3,4

Differential diagnosis for pseudologia fantastica includes dementia, delusional disorder, antisocial personality disorder, borderline personality disorder, factitious disorder, malingering, hypochondriasis, substance abuse/dependence, and schizophrenia/schizophreniform disorder.³

Table 2

DSM-IV-TR criteria for factitious disorder*

Intentional production or feigning of physical or psychological signs and symptoms
Motivation for the behavior is to assume the sick role
External incentives such as economic gain, avoiding legal responsibility, or improving physical well-being are absent
* Specifiers include with predominantly psychological signs and symptoms, with predominantly physical signs and symptoms, or a combination of both
Source: Reference 1

Table 3

Characteristics of stories told by patients with pseudologia fantastica

not entirely improbable
long-lasting, often repeated over years
self-aggrandizing
not told for personal profit
not delusions (when confronted with facts, patient can acknowledge the stories as falsehoods)
Source: Reference 2

A patient with pseudologia fantastica effectively weaves a fabric of lies in a dramatic style. When challenged, he or she improvises yet another story. Inconsistencies can be detected by spending time with the individual. The patient is consistently vague when asked to provide additional details. The reward is the attention.
Because of an unstable self image, the pseudologia fantastica patient constantly battles to regulate his or her sense of self. The dramatic production of symptoms due to this constant battle is thought to be a way for the patient to stabilize the self by making the experience of distress concrete and legitimate.⁵ It was fascinating to see Reverend R’s defense mechanisms work.

Confronting patients such as Reverend R likely is not the best approach. Showing them respect and empathy is important. Creating a safe, supportive environment in which they can express themselves will encourage them to consider ongoing psychiatric care.^3,6

OUTCOME: Return to nursing home

Approximately 1 week after our follow-up visit, Reverend R was discharged to the nursing home where he had resided prior to the hospitalization. Several attempts to contact him to obtain additional information and collateral history were unsuccessful, but clearly we had enough information to refute the reason we were asked to evaluate him.

Related resources

• Epstein LA, Stern TA. Factitious illness: a 3-step consultation-liaison approach. Current Psychiatry 2007;6(4):54-58.
  
• Birch CD, Kelln BRC, Aquino EPB. A review and case report of pseudologia fantastica. Journal of Forensic Psychiatry and Psychology 2006;17(2):299-320.
  

Drug brand name

• Sertraline • Zoloft
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.