Pathological lying and tasks of psychological assessment

According to Webster's dictionary 1, the definition of the word lying has double content: a) a speaker claims something that he/she knows or believes to be untrue with intent to deceive, b) to create a false image or a wrong impression. It is essential that the speaker knows that the content is false and intends to deceive someone. Thus, people with delusional disorder cannot be considered pathological liars even though they do not tell the truth. Lying is human behavior that can have its own normal and pathological forms of appearance. In daily life, people lie most often about their true feelings, incomes, achievements, sex life, and age . If we have a look at everyday lies we can see the extent to which people use untruths in their communication considering them neither immoral nor subjecting such statements to moral judgement.


Introduction
According to Webster's dictionary ¹, the definition of the word lying has double content: a) a speaker claims something that he/she knows or believes to be untrue with intent to deceive, b) to create a false image or a wrong impression.It is essential that the speaker knows that the content is false and intends to deceive someone.Thus, people with delusional disorder cannot be considered pathological liars even though they do not tell the truth.
Lying is human behavior that can have its own normal and pathological forms of appearance.In daily life, people lie most often about their true feelings, incomes, achievements, sex life, and age 2 .If we have a look at everyday lies we can see the extent to which people use untruths in their communication considering them neither immoral nor subjecting such statements to moral judgement.

"Normal" and pathological lying
There are individual differences among people in terms of frequency of lies, a degree of lies and objective they want to achieve.The motivation for lying is a result of complex mutual influences of conscious and unconscious contents.A lie is often generated from multiple sources 3 : lying to avoid punishment, to preserve a sense of autonomy ("Others do not need to know everything") and identity ("I do not love myself as I am, I will become someone else who is more attractive"), then, lying as an act of aggression with intention to inflict damage to others, as a way of fulfilling the desire (people make up what they want to happen), or as a way of getting a sense of power over partner, doctor, etc.Sometimes lies are told out of self-deception in order to boost and protect the suppression of self, as in the therapeutic process to prevent access to personal content related to the sense of personal weakness and failure.Lying may be motivated by the need to manipulate the behavior of others but also to help others.Lying is often motivated by the need for establishing self-esteem ("I'm not worth anything, so I have to lie to feel worthy or lovable").
Lying can be thought of as a defensive psychological strategy to protect a person from emotionally intense or traumatic events.If the events exceed the capacity of the person to deal with reality, they can use lies as a kind of fantasy and self-deception which falsifies reality, no matter if that reality is an everyday stress or some major life traumas.People who have experienced posttraumatic stress disorder (PTSD) due to exposure to the war, pathological lying has the function of protecting their psychological integrity 4 .This view emphasizes the role of lying in intrapsychic regulation, which is as important as the motivation directed towards external objectives -the person's need to be socially accepted and wanted.
When we face a patient who tells untruth, the question is: where is the line between "normal lying" (it is common to all people if they are exposed to certain circumstances) and "pathological lying"?Pathological lying is compulsive and impulsive, pervasive behavior of individuals (persistent and stable as a personality trait); its goal is not to achieve material gain and sometimes it has self-defeating quality (e.g.people lie even when it is harmful or dangerous for them, even in the judicial process) 5 .Lying becomes pathological if it interferes with normal development or is destructive to the quality of life and environment of the person involved 5 .

Classification of pathological lying
There are many divisions of lies with respect to various criteria.The classification of lies that are available in the literature are not comprehensive, because they do not include all categories and are not consistent because they are not based on a single criterion of division.
Pathological lying and Pseudologia Fantastica are not recognized as an entity in psychiatric classification systems.Only Munchausen Syndrome is classified as F68.1, while other subtypes of lying related to false identities or false accusations are omitted.In the discussions, it is often asked whether pathological lying is a symptom or syndrome; whether it should be coded on Axis I or in the category of personality disorders it is usually associated with.In any case, the lack of a code in the classification systems prevents detection and monitoring of the incidence of this phenomenon.
Pathological lying has its subtypes 3 : 1) Pseudologia Fantastica (PF); 2) liars by habit (they lie superficially, easily, often recklessly, it is easy to recognize their lies, they are often suggestible and have some neuropsychological abnormalities like learning difficulties or marginal intelligence); 3) lying and impulse control disorder (associated with gambling, kleptomania and compulsive shopping, when lying has a function of protecting obsessive needs a person is ashamed of, or has a need to conceal them in front of their environment); 4) people who live their lives by lying: impostors (during their life they change their identity, name, profession, origin in order to present themselves as important people) and confidence artists who change their identities in order to achieve material gain, 5) Munchausen syndromepeople who simulate disease, identify themselves as patients to get attention and care.Munchausen syndrome by Proxy (MSBP) caregiver fabricates and reports constantly new symptoms of diseases in those who are in their care, for example, mother in her child, a nurse who induces health problems in a patient who has been entrusted to her.
Among the categories of pathological lying PF is the most extreme form of pathological lying, which is a mixture of facts and fantasy.The person likes to lie and at the same time they experience pleasure in the process and are excited by the possibility to be discovered.The researches on lie detector tests have showed that people with PF experience stress while they are telling lies, which means that they are aware of their falsity 6 .Despite defective morality, it is possible that they have a certain feeling of guilt, and therefore, they convince themselves and others that their claims are true and keep their circle of lies strong by rigid attitudes.
Mythomania or pathological lying was first clearly entitled and described in 1891 by a German psychiatrist Anton Delbrueck.The first authors who contributed to this subject in English were Healy and Healy 7 .Their research conducted on a group of 1,000 juvenile offenders showed that the prevalence of pathological lying in juvenile offenders is about 1%, which means that it is even smaller in non-forensic population.One of the few studies of pathological lying on a sample of 72 cases finds that pathological lying begins with adolescence and lasts throughout the lifetime of a person 8 .
The intelligence is an average or slightly lower and 40% of the respondents has a central nervous system dysfunction such as epilepsy, abnormal EEG findings, brain trauma or a central nervous system infection.About 30% of exposed cases had a chaotic primary family and a history of mental illness among close relatives.People diagnosed with personality disorders are those who lie the most: antisocial, histrionic, borderline and narcissistic personality (Cluster B), and obsessive-compulsive personality disorder (Cluster C Personality Disorder) 3 .
The question is whether the PF is a symptom or syndrome, if it is sufficiently stable, consistent and predominant to be recognized as a basic psychopathological entity in a classification and whether it would be placed on the Axis I or Axis II.It is believed that pathological lying can be a primary and secondary according to whether it occurs in a person that cannot be diagnosed with other psychiatric diagnosis or in a person who has the symptoms of other psychiatric disorders 7 .However, our clinical experience tells us that it is difficult to assume that pathological lying can be isolated symptom without existence of other problems in the personality functioning, regardless of whether or not they meet the criteria for diagnostic classification of comorbidity.
Pathological lying of PF type can be identified on the base of the following criteria 8 : the stories are not so unbelievable and they are usually based on truth; a tendency to make stories is permanent / stable; the stories do not have a purpose of obtaining some material profit and have a quality of the grandiose self; a patient always presents themselves as the central figure -a hero or victim; they differ from delusions because the person knows that the stories are untrue.
People with pathological lying are inclined to structure their stories around the army and the police which, as the institutions, are bearers of social power.Presenting themselves as people who are influential in these organizations they give themselves special importance.People who are misled by their stories can treat pathological liars in a different way: they can disclose some professional secrets to them or give them more responsible professional and social tasks, or involve them in some social or political action.The available literature mentions eight cases of pathological lying that contain stories related to the army, paramilitary organizations or espionage wherein the person can represent themselves as a hero or a victim of the military system 9 .

The objectives of psychological testing
According to clinical experiences, people do not come for a treatment for pathological lying because they consider it ego-syntonic and feel no need to correct it.They see psychologists or psychiatrists because of other psychological symptoms or life problems which sometimes can be the consequences of their lying.Initially, false stories are more difficult to identify because the patients gradually introduce them as false fragments and then intensify and enrich them by extending communications in order to attract the attention of the examiner and conceal the real problems in their lives.Sometimes therapists tend to dismiss immediately or distan- ce themselves quickly from the patient who is dishonest because they consider honesty a prerequisite for therapeutic work or assume that this is a manipulation where the patient wants to stay in a psychiatric ward for some other purpose.In those situations, it is common to get suitable information from people who know the patient (to perform so-called heteroamnesis), but these patients often avoid bringing their relatives, partly because they do not want their story to be uncovered, and partly because they need time to gain confidence in the therapist who would not reject and condemn them because of their lies.They make up stories easily and without any signs of discomfort, over time they complicate and generalize the increasing number of situations.They are eloquent and able to remember clearly what they said, but if the therapist confront discrepancies in their story, they quickly justify them with new lies.During the confrontation they do not recognize the lie and continue to lie without showing any signs of shame and remorse.Longer and more serious work with the patient raises the question of differential diagnosis of this disorder and how much a psychologist using psychological tests can contribute to proper detection of the disorder.

Differential diagnosis
The first aim of psychological testing is primarily the differential diagnosis: differentiation between pathological lying (or the specific subtype PF) and confabulations, delusional beliefs and simulation.a) Pathological lying v.s.Confabulation: Unlike confabulations, in lying there is persistent quality of a story and there is no deficit of memory.Confabulations are the expression of unconscious feeling of a person that he/she has some gaps in their memory which must be compensated with an imaginary experience; the patient believes in confabulations but they have no basis in actual facts to corroborate them.Patients may be preoccupied with their confabulations which can arise in organic amnesia so the search for organic causes of mnestic deficit must be performed by objective methods.
The task of testing related to this dilemma: Is there a neuropsychological deficit especially problems in long-term memory and/or amnesia?Here neuropsychological tests, the Wechsler Memory Scale (WMS) 10 and the Wechsler Intelligence Scale (WAIS IV) 11 are used.b) Pathological lying v.s.delusional beliefs: in pathological lying, when a person is confronted with the facts, he/she is able to recognize their own stories as false.People with delusional disorder are not able to do that and when confronted with the truth they even become hostile; they have a strong need to defend their beliefs and keeps them encapsulated in relation to the real arguments.In pathological lying the person changes story elements and combines them with elements of reality, and in delusions the story is always the same and usually has a simpler structure.
The task of testing: Is the person psychotic?Here the following tests are used: intelligence tests, the questionnaires that really perform well in detection of psychosis (Personality Assessment Inventory -PAI 12 , Minnesota Multiphasic Personality Inventary -MMPI-2 13 ), the drawing projective test and the Rorschach method 14 .The Rorschach technique is particularly useful for estimating how well a person tests reality.Cluster mediation indicators just allow comparisons to what extent the respondent sees the reality the same way as most people, whether he/she does that in an idiosyncratic manner or creates perceptual distortion.One of the central diagnostic questions 15 is whether people with pseudologia have the reality test preserved or they believe in their lies as "wishful psychosis".Individual differences may be interesting and may show how the respondent is positioned on the reality testing dimension.Generally, we do not expect to find perceptual distortions or pathological errors of judgment in people with pseudologia but it is possible that they are characterized by idiosyncratic opinion that set them apart from the majority of people, as well as by a tendency towards arbitrary interpretation of reality.c) Pathological lying v.s.Simulation: in simulation, a person has a clear material gain obtained from the stories he/she makes up but stops telling them when there is no tangible benefit.In pseudologia, profit is psychological and lying often distorts the social status of people and contributes to their self-defeating behaviour.
The task of testing: Does a person have a tertiary gain by lying?Are there test indicators of simulation?A battery of tests is used and the indicators of validity and simulation in test materials are particularly valuable (validity scales of the PAI and the MMPI-2 questionnaires).The psychopathy and personality disorders scales used in questionnaires also contain items that indicate the behavior correlated with lying 16 .The PAI inventory scales should be carefully followed: problems with identity (BOR-I), Antisocial Behaviors (ANT-A), Egocentricity (ANT-E), Stimulus -Seeking (ANT-S).
Monosymptomatic scales relating to psychopathy (e.g.Psychopathy Checklist-revised, PCL-R) 17 often contain items related to the lying or Machiavellian orientation.However, a respondent easily recognizes such issues and denies socially unacceptable behaviours.Such questions are less conspicuous in the multidimensional questionnaires and if it is a Likert-type scale responses then there is a possibility of gradation which is more acceptable for the respondent.

Intelligence and neuropsychological assessment
The height and structure of a respondent's intelligence is the second task that can be tackled by the psychological testing as well as whether there is a specific neuropsychological profile of a person who pathologically lies.While the application of modern technology enables us to record the brain functioning, it is known that neuropsychological deficits observed by testing do not have to correspond with computed tomography (CT) or magnetic resonance imaging (MRI) of the brain.A test of general intelligence and the difference between verbal and nonverbal skills can be in the first place of importance.There are no major researches that will show the level of general intelligence of people who lie; a study on a sample of 72 cases of pathological lying has shown the intelligence levels between average and slightly lower, while verbal IQ was higher than non-verbal 8 one.In a recent meta-study 9 of 25 subjects, 19 had an average general intelligence score and there was no difference between verbal and nonverbal skills.It is logical that more complexly produced story requires a certain scope of general education, good attention, memory and the ability to combine the elements of the story.However, we do not have a sufficiently large group of respondents to verify that empirically and harmonize the method by always applying the same form of intelligence test.Only if we tested a sufficiently large group of patients, we could talk more reliably about whether there was a similarity in the general intelligence level and in the individual abilities structure of the group of people who pathologically lie.
The old dilemma of the psychology of individual differences is to which extent lying is hereditary-innate and how much it is a result of family and other social influences.Using neuroimaging people who lie were found to have significantly larger white matter volumes and slightly smaller gray matter volumes in the prefrontal brain structures compared to the groups of anti-social and normal subjects 18 .The prefrontal cortex is a brain area responsible for the process of remorse, learning of moral behavior and moral decisions.The larger white matter enables greater network of the prefrontal cortex, the faster flow of information which is connected to better verbal skills and a greater readiness to lie, while the reduction in gray matter represents lesser moral restraint and greater disinhibition when a person is telling a lie.An alternative hypothesis is that an increase in prefrontal white matter does not lead to greater functional efficiency but to disinhibition and increased lying 19 .Although there have been some earlier reports that in a group of people who lie even 40% of the respondents have a dysfunction of the central nervous system 9 , new technologies enable us to recognize better the structure and function of the brain that may be correlated with the tendency of people to lie 20 .
These recent findings raise the question whether there is a specific neuropsychological finding in a group of people who pathologically lie and what expected interrelationship (configuration) of individual cognitive abilities would be like.Neuropsychological tests that should be used taking into consideration the observed brain regions are: the Wisconsin Card Sorting Test (WCST), the Phonemic and Category Fluency Tests, Stroop test, Trail Making Test B (TMT B) 21 .

Assessment of comorbidity with personality disorders
The third objective of testing may be to establish whether the person also meets, apart from pathological lying, personality disorder criteria.Conclusion on comorbidity is important for medication and psychotherapy process because sometimes by treating another disorder we indirectly reduce the person's need to lie pathologically.Also, the presence of severe character pathology significantly complicates the therapeutic changes.For this purpose we use projective methods and self-descriptive questionnaires especially these which have the power to differentiate categories of personality disorder (Revised NEO Personality inventary -NEO PI -R 22 , Million Clinical Miltiaxial Inventary -MCMI III 23 , and PAI).

Determining the position of the trait Honesty (Falsity) in the modern theories of personality
The fourth task of testing may be positioning of lying in some personality model that is dominant now.Honesty (falsity as well as the phenomenon on the opposite pole) can be treated as a personality trait that is related and correlated to other wellplaced personality factors and aspects.It is particularly intriguing how this personality trait would be positioned in the fivefactor model of personality which is operationalized excellently through the NEO PI-R personality questionnaire.The theoretical hypothesis is that the tendency towards pathological lying correlates to the highest degree with aspects of the Agreeableness domain: (A1) Trust, (A2) Straightforwardness, and (A3) Altruism.The relation with other aspects is also probable: (N5) Impulsiveness, (E3) Assertiveness, (E5) Excitement Seeking, (O5) Openness to ideas.
Another model that might be a good frame of reference is the Honesty-Humilty-Emotionality-Extraversion-Agreeableness-Conscientrouness-Openess to expirience HEXACO model 24 in which the domain honesty-humility is set as the sixth factor of personality.This factor is based on evolutionarily developed altruism and initially it was named Honesty.It begs the question whether the tendency towards lying is a separate bipolar line or an extreme pole on some of the existing traits within these models (e.g.Honesty).It is also questionable whether mendacity (including pathological lying as extremization of this trait) is a trait of a lower order compared to honesty, altruism, manipulative or some other already operationalized trait within these models.These questions can only be answered by some research conducted on larger samples and factor analysis of the scores.

Understanding the role of lying in the dynamics of personality
The fifth task of testing is to recognize the role/motive of lying in a dynamic personality, in the family system or social environment.Although the diagnostic interview is the crucial here, we can get some useful information by using some of the family therapy questionnaires or those intended to assess the development and differentiation of identity.Namely, if we looked for the dynamic concepts in relation to lying, we would apply methods designed to measure ego and superego deficits, the degree of identity development, self esteem concept and it would be challenging to see what defense mechanisms are mainly used by people who have a problem of pathological lying.Monosymptomatic scale, individual subscales of the questionnaire and application of projective methods can help with examining the correlations between lying and these dynamic concepts.Thus, in the Rorschach method we have scales used to evaluate ego maturity and differentiation (e.g.Mutuality of Autonomy Scale 25 ).It would also be interesting to examine the interpersonal style of the person who pathologically lie, either through relationships of the Dominance (DOM) and Warmth (WRM) scale on the PAI inventory or by applying some of the questionnaires that test specifically the social tactics of the subjects.Thus obtained data are important for assessing both the potential for psychotherapeutic work and the choice of the therapy type.
Research papers on groups about the problem of pathological lying are old and rare; these are usually case studies 26,27 or in recent times, the results of neuroimaging studies.

Conclusion
The research base for this entity is very small because it is not recognized as a separate diagnostic category; we do not have operationalized criteria for its recognition, so there is no data on the prevalence in the general or psychiatric population.The rarity of the disorder and lack of agreement on the methodology that researcher will apply prevent clus-tering of the sample and results, including the integration of the findings of different researchers.We do not have consistent data on the amount and structure of intellectual abilities of these individuals, whether they express specific neuropsychological deficits, how they are positioned in today's dominant theoretical personality models or in relation to other psychiatric categories (particularly personality disorders).The use of modern neuro/psychological tests can give us the answers to numerous researches or diagnostic dilemmas appearing during the work with individuals who have a problem of pathological lying.The existence of an agreement among psychologists as to which tests will be administered in this category of patients and the development of an Internet database in one research center would allow the accumulation of results which could help us to better understand the phenomenon of pathological lying and to treat it more successfully.