This case report describes a 45-year-old man admitted to a psychiatric unit displaying dissocial personality disorder and pseudologia fantastica. During his admission, he provided elaborate stories but his behavior showed hostility, uncooperativeness, and a goal of being imprisoned or institutionalized long-term. He was diagnosed with dissocial personality disorder and pseudologia fantastica based on observations of his non-verbal behavior contradicting his stories. The report concludes factitious disorders and lies may be used by vulnerable people to access psychiatric resources and company. Ethnographic observation skills are important for psychiatrists to discern diagnoses.

1. Case Report
Presenter: Kapil Kulkarni
Guided by: Dr Shoka, Consultant Psychiatrist
Dr Lazzari, SpR
1
DISSOCIAL PERSONALITY DISORDER AND PSEUDOLOGIA
FANTASTICA: UNMASKING FACTITIOUS DISORDERS IN
PSYCHIATRIC INPATIENTS

2. 2
INTRODUCTION
• Since mankind appeared on
earth it has used lies for many
reasons: personal, existential,
convenience, amusement,
survival, etc.
• Yet, psychiatrists have been
called to understand if patients
presenting to their attention
are using lies to access goods
and services not otherwise
available should the truth be
disclosed.

3. 3
INTRODUCTION
• Therefore, unmasking factitious
disorders is becoming an ability
in general adult psychiatry. One
skill that is important in
psychiatric assessment is
observation.
• In its more scientific
application, ethnographic
research into patients notes,
understanding and deciphering
non-verbal behaviours are
vitals to reach a final diagnosis
in psychiatry.

4. 4
BACKGROUND
During psychiatric diagnosis, please
express in percentage the following:
1) Importance of what patients tell
us: VERBAL (what is said)
2) Importance of what we observe of
patients : NON-VERBAL (actions
and behaviors)
3) Importance of how something is
said: PARA-VERBAL (tone, volume
and rate of voice)

5. 5
BACKGROUND

6. 6
BACKGROUND
The following case will help
us develop basic skills in
reinforcing psychiatric
assessment of non-verbal
skills and in detecting
pseudologia fantastica in
psychiatric patients.

7. 7
DEFINITION
• “Pseudologia Fantastica is a
tendency to tell extravagant and
fantastic falsehoods centered
about the storyteller, who often
comes to believe in and may act on
them”.
• It is reported that pseudologues
(people who report PF) often
present with frequent job
variations, self-importance, and a
naïve and articulate use of
dialogue; in addition, they might
fake an illness as well, thus making
PF comorbid with Munchausen
syndrome.

8. 8
DEFINITION
• Fish also reinforces the idea that
PF is a form of lying that occurs
in people with DPD; furthermore,
people with PF describe various
key events and distresses and
usually tell these stories when
facing legal prosecutions.
• Moreover, as Sadock and Sadock
maintain, the attention and
curiosity evoked in the auditors
who listen to the story gratifies
the patient and, therefore,
strengthens PF.

9. • A 45-year-old white British
Caucasian gentleman
(identified as Mr. B) admitted
in PBU with following
complaints:
1. Feels suspicious
2. Non compliance with
medication
3. Physical aggression.
9
Presenting problems

10. • During the MHA, Mr. B.
reported that he had
deliberately smashed up his
mother’s house in order to
get sectioned and gain access
to prison.
• He said he had never been as
happy as during the two
months which he recently
spent in prison.
• There, he felt safe and
enjoyed the solitude, as he
was away from all the people
conspiring against him.
10
History of present illness

11. History of present illness
• On admission, Mr. B. reported a
complex and articulated story.
• He was feeing that somebody had
taken a video of him whilst using drugs
and uploaded it on the Internet.
• He said that he is being watched on
the internet like the “Turner Show.”
• He was convinced of this, because
people he knew were reacting as if
they had viewed this video.
11

12. History of present illness
• However, as he himself declared, his
intention in being admitted under
Section 2 was to be locked into a
prison or a psychiatric hospital forever.
• He added that he would do whatever
was needed in order to achieve this
goal.
• He believed that this would allow him
to live away from others and to
continue his exercises of ‘Buddhist
relaxation’.
12

13. History of present illness
• Mr. B. reported that he has
stopped taking his medication, as
he felt he did not need it and
adding medications has made no
difference in his life.
• Mr. B. also reported that he has
lost 25 kgs weight since stopping
the medication.
13

14. Past Psychiatric History
14
• Known to Mental Health Services since
2008.
• Record shows he is with Community
MHT since 2013 with diagnosis of
‘schizoaffective disorder’.
• Mr B denied that he was under the
CMHT Braintree, saying that he had
discharged himself.
• ‘Schizoaffective disorder’ was the
diagnosis which he strongly maintained
and for which he threatened staff
whenever this diagnosis was challenged.

15. Past Psychiatric History
15
• Moreover, he tended to use his
psychiatric diagnosis as a justification for
any threatening and challenging
behaviour, such as “I have ADHD and I
cannot stand/ deal with people.”

16. • Recent records show that Mr B
was on following from CMHT:
1. Quetiapine 300mg Nocte
2. Fluoxetine 20mg Mane
3. Zopiclone 3.75mg Nocte
• Before Quetiapine he was on
Aripiprazole 10mg Mane and
Olanzapine 5mg Nocte.
• On admission he was not on any
medications except Zopiclone
7.5 mg PRN. 16
Medication prior to admission
and on admission

17. Personal History / Social Circumstances
• Birth- Born in Basildon, and reports
delayed speech.
• No physical health problems as a child
reported.
• Education- Attended school until the
age of 14 and then went to college to
do course in bricklaying.
• Work- He worked in construction
industry and he reported that he
stopped working in 2005. He added
that he made lots of money and spent
everything.
17

18. Personal History / Social Circumstances
• Housing/accomodation- Mr B.
reports he is currently of NFA
(homeless) however this is
being looked into by staff.
• He reports he lived in Braintree
until 3 months ago but he was
evicted by police as he made
derogatory and homophobic
comments towards his
neighbors who he feels are all
gay.
• Finance- No debts. Currently
on ESA (Employment and
support allowance). 18

19. Personal History / Social Circumstances
• Mr B. extensively reads books
on psychology, and this was
believed by the team, as it could
have been the source of the
detailed story he had given of
himself and his beliefs and
different diagnosis which he
makes for himself.
19

20. Pre-morbid personality
• Interested in psychology .
• Says he follows Buddhism
and meditates regularly. He
practices ‘Buddhist
Relaxation’ exercise for long
period of time.
20

21. Family History
• Mr B.’s father left when he
was 11 years old, and he
has had no contact with
father.
• His mother is 73 years old
but he has a strained
relationship with her.
• He has one sister, whom he
has disowned and has had
no contact with her for the
past four years.
• He felt close to his
grandparents, both now
deceased. 21

22. History of substance misuse
• Mr B. smokes cannabis. Last
smoked a couple of weeks back.
• He was using cocaine regularly
between 1998 and 2003.
• Smokes rollies.
22

23. Forensic History
• Mr B. smashed up mother's
home - police involvement -
was at HM Prison Thameside
and released in January
2017.
23

24. Past and Current Medical History
• Medical history
unremarkable.
• No allergy known.
24

25. Mental state examination on admission
• Mr B was casually dressed and
unkempt.
• Rapport was well established and he
made good eye contact.
• Speech- coherent; normal in rate ,tone
and volume but loud at times.
• Cognition- Grossly intact.
• Mood- subjectively depressed,
objectively euthymic with reactive
affect.
• Thought- Mr B believes that people
are watching and talking about him, he
knows that he feels paranoid. No
formal thought disorder.
• Perceptions: Nil abnormal
• Insight- partial. 25

26. Physical examination
admission including
baseline observations
• Vitals within normal
limits.
• Neurological exam
within normal limits.
26

27. Results of investigations
• Bloods and urine -
Within normal
limits.
• ECG- Normal
27

28. Treatment and progress on the ward
• During the whole
admission there were no
sign of active psychosis,
abnormal perceptions,
low mood or mania.
28

29. Treatment and progress on the ward
• Mr B. remained
argumentative, challenging,
racist, and verbally
aggressive throughout the
whole admission.
• He refused any engagement
with the staff and medics
and tended to be
intimidating throughout the
period of stay.
29

30. Treatment and progress on the ward
• Management has not been easy
as the dissocial traits are very
marked and he was inclined to
bring excuses like ('I have ADHD' 'I
have a Schizoaffective disorder')
to justify his unacceptable
behaviour.
30

31. Treatment and progress
on the ward
• He escalated in his behavior
whenever the team and psychiatrists
challenged his beliefs and
mentioned that he might not suffer
from a schizoaffective disorder.
• However, as he himself confirmed,
his intent was not to avoid jail, but
the opposite—to be locked in
isolation either in a psychiatric
hospital or in a jail as “insane.”
• The risk of violence to properties
and to others remained high
throughout the admission.
31

32. Treatment and progress
on the ward
• This admission was improper as he
should have followed more a legal-
Police pathway instead of being
admitted into hospital.
• Mr B. scored low on the PIOS apart
from high score on ‘verbally abusive
and racist toward staff’ during the
whole stay.
• Alternatively, on the DPD-PF-AS
test, he scored high on all items.
32

33. Clinical
Ethnography in
Psychiatry
Ethnographic
Research: A Key to
Strategy
Ken Anderson
FROM THE MARCH 2009 ISSUE
…anthropological researchers …
observe and listen in a
nondirected way. Our goal is to
see people’s behavior on their
terms, not ours...
33

34. Rating scales- PIOS (Lazzari & Shoka)
34

35. Rating scales- PIOS (Lazzari & Shoka)
35

36. Rating scales- BPRS
• Brief Psychiatric Rating Scale
0 = Not assessed, 1 = Not present, 2 = Very mild, 3 = Mild, 4 =
Moderate, 5 = Moderately severe, 6 = Severe, 7 = Extremely severe
3.Anxiety= Mild
Worry, fear, over-concern for present or future, uneasiness.
8. Grandiosity=Mild
Exaggerated self-opinion, arrogance, conviction of unusual power
or abilities.
10. Hostility=Extremely severe
Animosity, contempt, belligerence, disdain for others.
11. Suspiciousness=Mild
Mistrust, belief others harbor malicious or discriminatory intent.
14. Uncooperativeness=Extremely
severe
Resistance, guardedness, rejection of authority.
17. Excitement=Moderately severe
Heightened emotional tone, agitation, increased reactivity.
36

37. Dissocial PD- ICD 10
37

38. Rating scales- DPD-PF-AS (Lazzari & Shoka)
38

39. 39
Rating scales- DPD-PF-AS (Lazzari & Shoka)

40. Rating scales DPD-PS-AS
40

41. Risk matrix
41
• At high risk for others and properties due to be easily frustrated if
his motives are challenged and if his desires are not fulfilled.

42. Risk matrix
• Risks identified:
1. Severe psychopathy
2. Conflict with others, threatening,
racial and verbal threats, easily
frustrated, intimidating. Reinforcing
'psychiatric symptoms' for achieving
the own agenda. Faking symptoms.
3. Risk to objects: Destruction of
properties in order to be put into
prison
4. Risk to self: minimal
42

43. Initial impression and diagnosis
• Dissocial Personality
Disorder with pseudologia
fantastica.
• Although reporting a
complex and articulated
history about being
watched on the Internet
like 'Turner Show', this had
no flavour of a delusional
disorder but a mix of
pseudologia fantastica and
probably overvalued idea.
43

44. Initial impression and diagnosis
• As he himself declared, his
intention was to be locked into
a prison or psychiatric hospital
forever and he will do
whatever is needed in order to
achieve this goal. The
differential diagnosis should
be posed with true psychotic
disorders.
44

45. Initial impression and diagnosis
• He believed that this will allow
him to continue with his
Buddhist relaxation and to live
away form others.
• He explained that his goal was to
live in isolation because he
cannot be into any social
environment as this 'will distract'
his Buddhist meditation.
45

46. CONCLUSIONS FROM THE STUDY
46
• Psychiatric observation of non-verbal behaviour is a
major route to psychiatric diagnosis.
• Psychiatrists should use ethnographic and
anthropological skills or field observation to confirm
diagnoses (‘Appearance and Behaviour’).
• What patient ‘says’ should not always guide primarily
the psychiatric diagnostic impression.

47. CONCLUSIONS FROM THE STUDY
47
• Psychiatric hospitals are attracting large strata of
population in search of a shelter, company and a
roof.
• Hence, psychiatric hospitals are considered a comfort
by underprivileged strata of population.
• As a consequence, people might use pseudologica
fantastica and factitious disorders to get quick access
to psychiatric hospitals.

48. CONCLUSIONS FROM THE STUDY
48
• It is predictable that psychiatric hospitals will attract an
increased number of people from those who feel alone,
homeless, and in search of company.
• Ethnographic psychiatry might highlight why people
use psychiatric symptoms to access privileged
psychiatric hospitals.
• In conclusion, presenting as ‘a psychiatric patient’ has
many advantages so more and more people might use
this route to gain access to psychiatric wards to
overcome feelings of solitude, homelessness, and
environmental violence.

49. 49