What Happens to a Pathological Liar with Acute Amnesia?

Following bilateral hippocampal damage caused by an acute stroke superimposed on an old, previously undiagnosed stroke, Mr. S, a 54-year-old man with narcissistic-psychopathic traits and a long-standing history of pathological lying, was admitted to our ward. He presented with anterograde amnesia and claimed he had lost his ability to lie. Mr. S underwent extensive neuropsychological testing and psychodynamically oriented psychotherapy one to two times per week. His emotional responses fluctuated between perceiving the stroke as both his salvation and his punishment, viewing the therapist as either caring or punitive, and regarding himself as omnipotent yet helpless. The medical team was similarly divided, with some viewing the patient as a malingerer and others perceiving him as severely impaired. We interpreted these polarized responses both from the patient and the medical team as consistent with a paranoid-schizoid position. From a neurofunctional perspective, we propose that these fluctuations were linked to the patient's fragmented perception across multiple domains, including memory, time, space, body, and self, alongside an impairment in his body's structural representation. Dynamically, we suggest that the patient's inability to lie revealed his underlying difficulty in tolerating the depressive position without the protective shield provided by his habitual pathological lying. We conclude that hippocampal function plays a crucial role in the psychopathology of pathological lying. Specifically, we propose that the creation of pathological lies relies on the same anatomical structures involved in memory formation. Dynamically, we argue that pathological lies serve a similar function to the manic defense, protecting against an unbearable depressive position.