The options available for treating PL have been poorly researched. The treatment modality mainly discussed in the literature is psychotherapy. However, there are no systematic studies on the effectiveness of psychotherapy in treating PL and no discussion of pharmacotherapy or any other types of interventions. It is possible that there may be a subset of pathological liars for whom pharmacotherapeutic options may help in reducing impulsivity or the compulsions associated with the urge to lie. In addition, further investigation of CNS abnormalities may lead to other therapeutic interventions. To fully embark on an exploration of treatment options for PL, however, it should first be recognized as a diagnostic entity. PL currently exists as a common but unessential symptom of factitious disorder. As in other medical or psychiatric conditions, emphasis is usually on the treatment of the condition as a whole and not necessarily the treatment of its individual symptoms.
Therefore, PL should be recognized as a diagnostic entity to encourage research into its treatment. The possible consequences of PL for the liar are severe. All relationships of the liar are at risk for destruction resulting from lack of trust and credibility. The shame of socially or formally interacting with others in the company of a spouse who lies repeatedly could overwhelm the relationship. In the workplace, as their lying behavior becomes increasingly clear to their colleagues, pathological liars stand the risk of bearing the brunt of rude jokes, being alienated, or being fired. In clinical situations, the therapist has the arduous task of overcoming not only the negative countertransference of treating a habitual liar but also the frustrations of not knowing which of the patient's statements are true.
Although most individuals affected with PL may not have cause to seek treatment and may indeed continue to lead highly successful and productive lives, it is not uncommon for their lies to cause them hardship through clashes with the law or other authorities, with resulting adverse consequences. For example, a purposeless false accusation, a recognized presentation of PL, is a criminal behavior for which the pathological liar may be prosecuted. This type of false accusation should be differentiated from false accusations for revenge purposes, or those that may occur in mass hysteria (for example, the Salem witchcraft phenomenon), in which a false idea generates intense anxiety that quickly spreads and may lead to baseless accusations.
It is perhaps in the forensic psychiatric arena that the need to clearly define PL is most urgent. The immediate question in these settings would revolve around the issue of competency of the pathological liar to stand trial. The criteria for being competent to stand trial include an ability to work collaboratively with one's attorney in order to confront one's accusers. A defendant who lies frequently and repeatedly to his attorney would ultimately confuse the attorney, making it difficult to formulate a sound strategy of defense.
Another problem is the risk of the pathological liar being accused of perjury when he gives false testimony under oath. In the case of Judge Couwenberg, the State of California Commission of Judicial Performance noted that he did not have a mental condition that excused or mitigated his behavior. The commission concluded that the mere presence of a symptom without any mental disorder is of little legal consequence.
It is easier to argue that PL is not a delusion than it is to say that pathological liars always have control over their lies. Koppen13 observed that the lie ultimately wins power over the pathological liar, so that mastery of his own lies is lost. In addition, PL has a compulsive or impulsive quality. Would it be feasible to say that in some cases the lying behavior was uncontrollable? Such a conclusion, when combined with recent evidence of possible CNS abnormalities in PL, would raise doubts about the degree of responsibility of pathological liars when their lies lead to criminal behavior.
In conclusion, PL is a special form of lying, narrow in its definition and complicated in its presentation. Its apparent rarity may be the consequence of lack of awareness of the phenomenon by clinicians. Unfortunately, it periodically causes significant hardship to the pathological liar. Psychiatrists confronted with pathological liars should complete a thorough clinical evaluation and obtain a longitudinal history of their lies, especially through collateral information from relatives, friends, and employers. In addition to psychotherapeutic treatment, psychiatrists should consider research into the usefulness of pharmacotherapy for impulsivity or compulsive behaviors in these patients.