1. The patient, a 73-year-old man, was referred for evaluation because he was yelling at and threatening staff. He has a history of lying, stealing from neighbors, and abusing his now-deceased wife. 2. On examination, the patient was grandiose, exaggerating his accomplishments and denying any problems. Testing found no cognitive impairments. 3. The evaluator determined the patient has narcissistic personality disorder, sociopathy, and engages in pathological lying. He lacks empathy and exploits others to boost his self-image. Treatment focuses on not challenging his delusions but providing feedback on how his behavior affects others.

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Mental Health Consultation
Patient Name: narcissistic personality disorder, sociopathy and pathologic lying
Date: x-xx-xx Facility: XXXX
Additional history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: 73-year-old, white, widowed, male… I was asked to evaluate him
because he was “yelling and swearing at staff… threatening to have them fired”. According to
staff, “He lies all the time…even when there seems to be no reason to lie… we think he is
stealing things from other residents…he denies this when confronted”. He was admitted from
XXXX on 6-5-xx where he had been taken after he was found “wandering into neighbors’
houses”.
Background Information:
He is alienated from his 5 children. He has had no contact with them in years. Reportedly, two
sons are in prison and he had a history of abusing his wife before her death 5 years ago. There is
some suggestion of a history of ETOH abuse in his record.
Recent labs and neuroimaging were unremarkable. CBC and CMP were mostly WNL and CT
scan of the head and MRI of the brain showed only mild cortical atrophy.
Current Medications: Lipitor, Acetaminophen, Flomax, Verapamil ER.
Medical History: Vitamin D deficiency, COPD, GERD, Hyperlipidemia, BPH, C-Diff,
Hypertension
Mental Status Exam: He was a spry gentleman wearing a motorcycle hat which was much too
small for his head and which had a comical effect. He said, “I had 300 guys in my motorcycle
club; most of them are dead now”. He went on to brag, “I was once Mr. America - Mr. Universe
… I studied to be a doctor…My father was both a doctor and a lawyer”. He was quite grandiose.
He was a gregarious, glad-handing type person who was anxious to please and to impress. His
speech was slightly pressured but coherent and relevant. When I asked what he did for a living,
he responded, “I wheeled and dealed”. He denied any mood problems or memory problems; “I
have a photographic memory” He was oriented to person, place and time. He did well on an
MMSE scoring 28 out of 30 points. His insight and judgment related to his situation were poor.
There were no overt hallucinations or other psychotic symptoms.
Findings: He is not demented, delirious or psychotic. He was not “wandering” into neighbors’
homes because he was confused; he was helping himself to their food and anything of value
which caught his attention. He told me he has a long history of this kind of behavior. The
behavior runs in his family; two of his sons are in prison. His problem behaviors are a reflection
of severe character pathology in the form of narcissistic personality disorder, sociopathy and
pathologic lying
He appears to have a narcissistic personality disorder, which is characterized by a pattern of
grandiosity, a need for admiration and a lack of empathy. Because people with this disorder lack

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empathy they are unable to identify with the needs and feelings of others. Others are there to
serve and be exploited. Their tendency to exploit comes from their belief that they are owed what
they are demanding. They see people that bend to their domineering personality as below them
or less important because they can be exploited. They assume that people will do as they are told
and will instantly respect them.
Typically, these people are preoccupied with fantasies of success, power, brilliance and beauty.
An exaggerated sense of self-importance and uniqueness is manifest in a pretentious, boastful,
overestimation of abilities and accomplishments and resentment about not having been
recognized for their "true" talents. Individuals with this personality style believe that they are
exempt from the duties and responsibilities of everyday people. They seek special treatment,
immediate compliance with their demands and they try to control others in order to feel
important and special. They expect others to treat them in manner consist with a level of
attainment they have not earned. Offense is easily taken at anyone who does not bow to them and
their belief in their own superiority.
They believe that they are exceptional or distinctive in some way and can only connect to others
who hold the same elevated status. As a result, they attempt to associate only with others they
perceive as high-status. These individuals never get enough compliments, recognition, or praise
and if others fail to meet their needs they will be derided or belittled. Failure or even less than
perfect performance by them results in excuses and blaming others. There is never ownership of
misdeeds or lack of success. They often live in a dream world or false reality; this false world
allows the person to maintain overbearing behavior and unrealistic beliefs about themselves but
they are not outright delusional or otherwise psychotic. About 16% of Americans suffer from
some degree of narcissistic personality disorder.
Persons with antisocial personality disorder (sociopathy) lack loyalty and honesty which
prevents them from achieving enduring satisfactory relationships. Although their apparent self-
confidence and glib assurances may be appealing, their inability to provide meaningful
descriptions of their motives and feelings is an obstacle to achieving intimacy with others. They
fail to sustain commitments, evade obligations, and betray promises. They are callous,
irresponsible and selfish. Impulsivity is a central feature of the disorder which can be evident in a
failure to show normal caution and in outright recklessness. They are easily bored and the
impulsive behaviors are often driven by a need for excitement. Also, often seen in sociopathic
personalities is pathological lying, manipulative behavior, lack of remorse or guilt, shallow affect
and a parasitic lifestyle.
Most people will tell some sort of lie from time to time, but pathologic lying is not typical
human behavior. The habit of lying uncontrollably is associated with several mental health
diagnoses including: narcissistic personality disorder and antisocial personality disorder. People
who lie pathologically are thought to operate with a clear motive in mind. They may lie to gain
personal attention or to appear more admirable. They lie repeatedly about important as well as
unimportant matters. Even after their falsehoods have been exposed, people who lie
pathologically may still have difficulty admitting the truth. What follows are characteristics of
the pathological liar:
 a pathological liar may study the person they hope to take advantage of by looking for
weaknesses.

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 the liar does not have any moral consciousness of how the lying behavior may make
others feel. The liar lacks the ability to consider what others might feel in response to
their lie (empathy).
 the pathological liar shows no emotion when lying which makes them believable.
 many pathological liars (and sociopaths) use sexual or emotional arousal to distract others
from the truth.
 some pathological liars show no discomfort when caught lying, while other liars may
become aggressive and angry when caught.
Recommendations:
1. Staff should avoid appearing directive with him. He would see this as a threat to his self-
esteem and become oppositional as a means of asserting his autonomy. Always allow him
a face saving way out of a conflict or situation. Discourage his acting out but be matter-
of-fact; avoid any statements which he could perceive as moralistic or personally critical
of him.
2. When he becomes verbally aggressive ignore the overt content of his remarks and
respond to the underlying feeling: “You seem to get angry when you think others are
thinking they are better than you.” Model self-regulation by speaking and moving slowly
when with him.
3. Do not allow him to make you feel responsible for immediately solving his problems. Do
not allow him to lure you into agreeing with his criticisms. Do not be intimidated by him.
Do not try to win his approval.
4. Don’t challenge his grandiose productions but don’t encourage them either; get him
talking about only realistic accomplishments.
5. Encourage him to take time away from people and the need to gain approval; a solitary
hobby is or meditation may be beneficial.
6. Encourage him to try putting himself in the shoes of the people around him.
7. In order to improve self-awareness, provide him with continuous feedback concerning
how his behavior affects others. Try using audiotape of his interaction with others. He
must perceive this feedback as non-judgmental.
________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist