Pathological Lying: Psychotherapists’ Experiences and Ability to Diagnose

The concept of pathological lying as a psychiatric condition was documented more than 150 years ago. In 1868, Wharton described pseudomania as a “morbid lying propensity” (1). Several decades later, G. Stanley Hall published an article (2) about excessive lying by children. As Hall was carrying out his work in the United States, a German psychiatrist, Anton Delbrück, was also studying pathological lying. In 1891, Delbrück wrote about several people whose patterns of lying were so far outside the bounds of normality that he deemed it a pathological condition he called “pseudologia phantastica” (3).

Healy and Healy (4) added to the literature on pathological lying by discussing several case studies and an investigation of 1,000 juvenile criminal offenders. They estimated that approximately 1% of the offenders they studied met the criteria for pathological lying. They defined pathological lying as “falsification entirely disproportionate to any discernible end in view . . . [that] rarely, if ever, centers about a single event. . . . It manifests itself most frequently by far over a period of years, or even a lifetime. It represents a trait rather than an episode. Extensive, very complicated fabrications may be evolved” (4). Healy and Healy also noted that pathological lying, mythomania, pseudologia phantastica, and other such terms were labels for the same disorder. King and Ford (5) analyzed 72 case studies of pathological lying and reported that onset was typically in adolescence, men and women were equally represented, and individuals tended to have average to above average intelligence. More recently, additional cases of pathological lying have been documented, yet researchers claim that the disorder remains understudied and not well understood (6–8).

Scholars who recognize the existence of pathological lying have argued the merits regarding it as a distinct disorder. Some (9, 10) have suggested that pathological lying should be viewed as a symptom of other psychological disorders. Although deceit is a potential symptom of antisocial personality disorder, pathological lying has not been discussed as a symptom (11). Furthermore, antisocial personality disorder generally involves a defiance of authority and lack of remorse, whereas people who endorse engaging in pathological lying show distress about their behavior (12). The DSM-IV-TR (13) indicates that individuals with factitious disorder may engage in pathological lying about aspects of their history or symptoms. Dike (14), however, argues that pathological lying is not a symptom of factitious disorder but a distinct disorder that can be understood as a superordinate category, with factitious disorder a narrower subcategory of pathological lying. Dike and colleagues (15) proposed the notion of primary and secondary pathological lying, with the former as an independent diagnostic entity and the latter involving conditions associated with pathological lying. Dike and other scholars (4, 12, 16, 17) have argued that pathological lying is a separate diagnostic entity. These debates and the historical lack of empirical support for a pathological lying diagnosis may have contributed to the condition’s exclusion from major nosological systems, such as the DSM-5 and ICD-10 (11, 18).

We previously reported a theory-driven study of 623 people (12) that provided empirical support for pathological lying as a unique diagnostic entity. Findings from the study revealed the prevalence of pathological lying to be 8%–13%. Individuals with pathological lying behavior reportedly told an average of 10 lies per day (mode=1) and had been doing so for longer than 6 months. Additionally, the excessive lying was found to impair their functioning, bring about distress, and put the individual or others in danger. The onset of pathological lying was most commonly during adolescence. Individuals exhibiting pathological lying were no more likely to report being diagnosed as having a psychological disorder than those who were not identified as exhibiting pathological lying, indicating that pathological lying may be a distinct condition. On the basis of these findings, we defined pathological lying as “a persistent, pervasive, and often compulsive pattern of excessive lying behavior that leads to clinically significant impairment of functioning in social, occupational, or other areas; causes marked distress; poses a risk to the self or others; and occurs for longer than 6 months.”

According to this definition, lies are told broadly, without a specific targeted benefit, such as that found in factitious disorder or malingering. This definition is consistent with the suggestion from Dike (14) that pathological lying is a broad superordinate category. Additionally, with this definition, the risks involved in this behavior are related to danger to self or others because of the patient’s lies (12). A recent study (19) found that people who interacted with those showing pathological lying behavior gave examples of harm to the individual, such as loss of jobs, imprisonment, loss of income, and divorce and other relationship problems.

Although there has been a plethora of case studies documenting pathological lying, clinician suggestions of a separate clinical phenomenon, and empirical evidence supporting pathological lying as a distinct diagnostic entity, practitioners’ experiences with pathological lying have remained largely unexamined. The purpose of the current study was twofold: to examine psychotherapists’ experiences and beliefs regarding pathological lying and to examine practitioners’ abilities to diagnose pathological lying. We predicted that more than half of the practitioners surveyed would indicate that pathological lying should be recognized as a diagnostic entity. Given the various historical cases and prevalence of pathological lying (4, 12), we predicted that some clinicians would report having worked with patients who exhibited pathological lying. Regarding the validity of diagnosis, we predicted that practitioners would accurately discern pathological lying from other psychological disorders.

Methods

Participants

Because the focus of the study was to recruit practitioners, participants were recruited from the Association of Psychology Postdoctoral and Internship Centers’ online directory for internship programs (N=291), an e-mail list of practitioners from the Texas State Board of Examiners of Psychologists (N=10,308), an e-mail to the Texas Society of Psychiatric Physicians, and through snowball sampling. Because of the snowball sampling, it is unclear how many people received the e-mail. In addition, we were notified that some e-mail addresses were not current. The only inclusion criterion was that the participants had some experience as a practitioner. A total of 374 participants were recruited, and 79 were excluded because of incomplete items or because they indicated having no direct contact hours with patients, resulting in 295 participants. On the basis of the number of participants who responded (N=374) and the approximate total e-mails sent (N=10,599), the response rate was low (3.5%).

Measures

This study included a questionnaire on demographic characteristics, the Survey of Patients’ Pathological Lying Behaviors (SPPLB), and four case vignettes (available in the online supplement to this article). Participants were asked to provide information about age, sex, ethnicity, education, current work setting, licensure, theoretical orientation, years in practice, and patient hours. The SPPLB is a 21-item survey based on the Survey of Others’ Pathological Lying Behaviors (12). The survey asked participants to report whether they had worked with patients who had engaged in or reported pathological lying behavior and the patients’ frequency of lying, functioning, and feelings of pain (distress) and the risks the participants had perceived related to the patients’ lying behavior. Items related to patients’ functioning, feelings of pain/distress, and danger from lying were rated on a Likert-type scale (1, strongly disagree, to 7, strongly agree; see SPPLB in the online supplement). Finally, four case vignettes of various psychological disorders were presented: two cases of pathological lying, one from Thom and colleagues (20) and one we created; one case of antisocial personality disorder from Covrig and colleagues (21); and one case of trichotillomania from Curtis and Kelley (22). These vignettes were selected to determine whether the participants could distinguish pathological lying from a disorder that has been suggested to have some overlap with features of lying (antisocial personality disorder) and a discrepant disorder (trichotillomania). With the exception of one pathological lying vignette, the other vignettes were selected from published cases. Prior to reading the vignettes, the participants were provided with definitions of deception, delusion, and pathological lying. After each case study, the participants were asked whether the person portrayed in the vignette met the definition of pathological lying; whether there were any additional diagnoses for the person; and, if the person in the case presented did not meet the definition for pathological lying, what diagnosis would be appropriate.

Procedure

The institutional review board of Angelo State University approved the study. Subsequently, the researchers e-mailed practitioners and directors a link to the study. When the link was clicked, participants were presented with the SPPLB. The participants were then provided with the option to continue to the vignettes portion. Participants were also asked to provide demographic information. Finally, the participants were provided a debriefing and asked to share the study with colleagues.

Results

Of the 295 participants, 171 were women, 76 were men, and 48 did not indicate their sex. Participants indicated a range of ages from 26 to 83 years (mean±SD=51.45±14.73), and a majority were Caucasian (N=238, 81%). Participants also identified as Latinx (N=19, 6%); African American or Black (N=14, 5%); Asian, Asian American, or Pacific Islander (N=9, 3%); Native American (N=3, 1%); and biracial or multiracial (N=12, 4%). Most participants held a doctoral degree (N=233, 79%) and some held a master’s degree (N=58, 20%). Most participants were licensed psychologists (N=225, 76%), and others were licensed as psychological associates (N=28, 10%), professional counselors (N=16, 5%), marriage and family therapists (N=5, 2%), and psychiatrists (N=3, 1%). The participants had trained in clinical psychology (N=170, 58%), counseling psychology (N=60, 20%), school psychology (N=62, 21%) and psychiatry (N=3, 1%). More than half of the participants worked in private practice settings (N=152, 52%). The participants indicated a range of theoretical orientations, mostly cognitive-behavioral (N=154, 52%), integrationist and/or eclectic (N=45, 15%), and psychodynamic and/or interpersonal (N=38, 13%). Participants’ years of counseling ranged from <1 year to 54 years (mean=20.63±13.26) (Table 1), and their direct patient or client contact hours ranged from 2 to 120,000 hours (mean=8,571.10±16,604.35).

A frequency analysis of all the participants revealed that more than half (N=152, 52%) had indicated that pathological lying should be considered a diagnostic entity. A majority of the clinicians (N=218, 74%) indicated that they had worked with a patient they considered to exhibit pathological lying (N=293, χ²=69.79, df=1, p<0.001). Of these practitioners, more than half (N=215, 59%) believed that pathological lying should be a diagnostic entity (N=215, χ²=6.37, df=1, p=0.01). A greater percentage of practitioners who had worked with patients they considered to exhibit pathological lying believed that pathological lying should be considered a diagnostic entity (mean=59±49) than did practitioners who had not worked with patients they considered to exhibit pathological lying (mean=34±48; t=6.87, df=130.89, p<0.001, d=0.51). Clinicians worked with an average of 40 patients (mean=39.92±371.99, median=1, mode=0) they had considered to exhibit pathological lying because the patient had explicitly stated struggling with excessive lying behavior, and with an average of 60 patients (mean=59.88±363.27) they considered to exhibit pathological lying because of other information the patients had provided. A smaller proportion of practitioners (N=60, 20%) indicated that they had patients (mean=12.75±31.58) who had come to them with pathological lying as the presenting problem (N=292, χ²=101.31, df=1, p<0.001). Most of the respondents (N=129, 88%) indicated that people with pathological lying behavior constituted <10% of their caseloads (N=147, χ²=311.42, df=3, p<0.001).

Most practitioners (N=127, 86%) indicated that their patients exhibiting pathological lying behavior had lied to them during their work together (N=147, χ²=299.88, df=3, p<0.001). Clinicians estimated that such patients told an average of 11 lies per day (mean=11.01±15.97; median=5, mode=5; N=73; maximum=100; 95% confidence interval [CI]=7.29–14.74; skewness=3.144, standard error [SE]=0.28; kurtosis=13.28, SE=0.56). Practitioners’ assessments of how pathological lying affected such patients’ functioning across areas of occupation, social relationships, finances, and legal contexts were compared by conducting a repeated-measures multivariate analysis of variance. Statistical significance was found across areas of patients’ functioning (F=58.97, df=3 and 132, p<0.001), whereas pairwise comparisons revealed that the participants indicated that the patients’ area of greatest impairment was in their social relationships (mean=6.30±1.16, p<0.001) (Table 2). A one-sample t-test was used to compare the participant accounts of how their patients’ lies caused distress for the patients with the mean distress caused by lies among a nonpathological lying sample (mean=2.21) from a previous study (12). A statistically significant difference was found (t=13.83, df=141, p<0.001, d=1.16). The pathological lying caused greater distress (mean=4.34±1.83) than did lying among the nonpathological sample (mean=2.21±1.65).

The participants predominately indicated that their patients’ onset of pathological lying had begun in adolescence (N=144, χ²=48.56, df=3, p<0.001). Of the clinicians who reported knowing how long their patients had been telling lies, a majority (N=106, 99%) indicated that their patients had been engaged in pathological lying for more than 6 months. Clinicians largely indicated that their patients had been engaged in pathological lying for more than 5 years (N=144, χ²=156.83, df=5, p<0.001). Most of the clinicians indicated agreement (mean=5.44±1.64) with the statement that their patients’ lies tended to grow from an initial lie (N=142, χ²=92.25, df=6, p<0.001). However, the participants did not indicate clear agreement on whether their patients’ lies were outside the patient’s control (mean=3.91±1.94, N=141, χ²=4.31, df=6, p=0.64) or whether the lies were told for no reason (mean=4.06±1.90, N=144, χ²=5.92, df=3, p=0.43) (Table 3).

A majority of the clinicians who had worked with a patient who had engaged in pathological lying (N=97, 68%) indicated that they had provided the patient with a formal diagnosis (N=142, χ²=19.04, df=1, p<0.001). The participants had provided a variety of diagnoses, with more than half (N=64, 56%) indicating they had diagnosed the patient with a personality disorder. The personality disorders diagnosed were antisocial personality disorder (N=18, 16%), borderline personality disorder (N=15, 13%), narcissistic personality disorder (N=7, 5%), and a general personality disorder or a mix of personality disorders (N=22, 15%).

Treatments Suggested

The participants suggested a variety of treatments for the condition. A frequency analysis showed that most clinicians suggested the use of cognitive-behavioral therapy (CBT) as part of treatment (N=101, 73%, and of these practitioners, 41% (N=57) suggested using CBT alone. In addition to CBT, practitioners suggested dialectical behavioral therapy (N=17, 12%), behavioral therapy (N=10, 7%), acceptance and commitment therapy (N=6, 4%), emotion-focused therapy (N=3, 2%), or motivational interviewing (N=2, 1%). Less frequent responses included suggestions for certain interventions or techniques or practitioners indicating that they were not sure.

Identification of Pathological Lying in Case Vignettes

To examine the hypothesis about practitioners’ abilities to recognize and accurately diagnose pathological lying when provided with diagnostic criteria, 156 participants read the vignettes and responded. Overall, the participants’ average percentage of discerning pathological lying from antisocial personality disorder and trichotillomania was 84% (N=156). A majority of the participants were able to accurately diagnose both pathological lying case vignettes (case 1: N=156, χ²=6.56, df=1, p=0.01; case 4: N=138, χ²=61.33, df=1, p<0.001) and not diagnose antisocial personality disorder or trichotillomania as pathological lying (case 2: N=143, χ²=139.03, df=1, p<0.001; case 3: N=133, χ²=96.01, df=1, p<0.001). Additionally, we used an analysis of variance (ANOVA) to examine whether there was a difference between the participants’ educational degrees and the number of correctly identified cases, and no significant differences were found (F=2.27, df=2 and 123, p=0.11). Furthermore, an ANOVA revealed no statistically significant relationship between participant licenses and the number of correctly identified cases (F=1.00, df=5 and 121, p=0.42). A bivariate correlation revealed no significant relationship between years of experience and the number of correctly identified cases (N=127, r=0.07, p=0.41).

Discussion

Although numerous case studies have provided evidence of pathological lying, the condition has yet to be recognized in major nosological classification systems. Recently, the authors provided theory and research to support pathological lying as a diagnostic entity (12). The current study expanded on those findings, offering additional support for the recognition of pathological lying as a distinct psychological disorder.

More than half of the practitioners responding indicated that pathological lying should be recognized as a diagnostic entity. Furthermore, a majority of the participants indicated that they had worked with a patient whom they considered to struggle with pathological lying. Most of these practitioners indicated the need for pathological lying to be recognized as a distinct psychological disorder. Because pathological lying is absent from nosological systems, the practitioners reported that they had diagnosed their patients as having other disorders, most often personality disorders.

The participants indicated that people with pathological lying behavior composed <10% of their caseloads. Although most patients have lied in psychotherapy, most do not lie often (23). The estimated caseload closely resembles the overall prevalence of pathological lying (8%–13%) (12). Patients exhibiting pathological lying were found to tell numerous lies each day (mean=11, mode=5). Moreover, the participants reported that their patients had been telling excessive lies for >6 months. Most of the participants indicated their patients had been excessively lying for more than 5 years. These findings closely match the frequencies of lies told and the duration of pathological lying found in other research (12). The participants also indicated that their patients’ lies often impaired areas of functioning, primarily social functioning, and generated psychological distress for their patients. These findings (i.e., persistence, pervasiveness, significant clinical impairment, marked distress, and posing a risk to self or others) represent the markers that help distinguish people with pathological lying from people who merely lie a lot (12, 24, 25). The participants indicated that their patients typically experienced onset of pathological lying during adolescence and that the lies told tended to grow from an initial lie, paralleling accounts from individuals with pathological lying behavior (12).

The participants provided several treatment suggestions for pathological lying, mostly CBT, dialectical behavioral therapy, or behavioral therapy. However, the practitioners did not indicate whether these treatments were effective. CBT has previously been suggested as a prospective treatment for pathological lying (16). However, because pathological lying is not recognized as a diagnostic entity, “there are no systematic studies on the effectiveness of psychotherapy in treating [it]” (16). Researchers and clinicians may want to explore the utility of implementing CBT and pharmacologic interventions for pathological lying (16).

The practitioners were largely able to recognize and properly diagnose pathological lying when it was presented and to distinguish it from other disorders. Some arguments about the distinctiveness of pathological lying have been that it is a symptom of other disorders, namely personality disorders (9, 10). The current study provided discriminant and convergent validity for the participants’ ability to discern pathological lying as a psychological disorder, encompassing specific symptoms and criteria, distinct from antisocial personality disorder and trichotillomania. Taken together, these findings support the claim that pathological lying is a distinct disorder (4, 12, 14).

This study was limited by the response-driven sampling method and the low response rate, which may have produced a sampling bias. The study may have attracted practitioners who were interested in deception or pathological lying and those either in favor of recognizing pathological lying as a diagnosis or opposed to such recognition. Thus, the sample may have produced response bias and may not represent other clinicians’ experiences. The study also lacked ecological validity. Although vignettes are often used within clinical training, the current study did not explore whether clinicians would have been able to determine a diagnosis without the patient explicitly reporting pathological lying behavior or being directly asked to discern whether the patient met criteria for pathological lying. Some professionals may not be highly accurate in detecting deception, and additional training in emotion recognition does not improve the ability to detect deception (26, 27).

Future research may explore whether psychotherapists using a full battery of assessments and evaluations to aid in diagnostic determinations can determine pathological lying through those means. Researchers and practitioners could conduct psychological evaluations or examine assessment profiles of patients who are engaged in pathological lying. Future research could also explore randomized clinical trials of the suggested psychotherapy (e.g., CBT) and pharmacologic treatments for pathological lying.

Conclusions

In this first study of its kind, to our knowledge, we surveyed a large number of mental health professionals about their experiences working with patients who exhibited pathological lying. Although the study had a low response rate, most of the respondents had worked with patients who engaged in pathological lying. These findings add to documented case studies and recent empirical evidence of pathological lying existing as a distinct disorder with unique, valid, and discernable symptoms (4, 5, 12). The participants’ widespread experience with patients who engage in pathological lying supports consideration of including pathological lying in major nosological systems. Nosological systems are tools that hold both great benefit and some risks. As it stands, people who struggle with pathological lying are not provided with an accurate diagnosis, and our findings indicate that they often receive another diagnosis. Thus, people are potentially provided treatments that are ineffective in resolving their core symptoms. Because these practitioners reported working with people exhibiting pathological lying, adding the condition as a formal diagnosis might allow practitioners to fully recognize pathological lying, provide an accurate diagnosis, and implement the most effective treatments. A potential concern of including pathological lying as a formal diagnosis would be negative attitudes that practitioners may hold toward patients who lie (28). However, this concern could be remedied by implementing curricula and educational workshops related to pathological lying and by practitioners striving to more fully understand the function of the lies rather than taking a defensive stance against the patient (28–30). Collectively, recognition of pathological lying as a diagnosis could provide practitioners, patients, and the public with a more accurate picture of individuals who engage in this behavior, not as malicious but as people experiencing distress and impaired functioning.