To believe or not to believe: that is the question
I remember, when I was a kid, listening to a radio program in which a man who had started a movement to dress up farm animals was being interviewed. The position he took was that cows standing around with their udders visible were sexually provocative and unseemly. It sounded to me like a serious conversation. I knew that dressing up cows was a stupid idea, but it seemed no more stupid than other things I heard about regularly. I was taken aback, therefore, and embarrassed, to discover that it was a hoax. I had allowed myself to be taken in.
More than most people I know, I have a thing about not being deceived. I am skeptical. This is a matter of some significance when talking to patients. When they tell me something, they have a right to expect that I will take them seriously and put some credence in what they tell me. Yet, in order to help them, I really need to know the truth about them; and it has become apparent over the years that some patients—who have no obvious reason to deceive their psychiatrist— have told me fantastical stories.
Of course, I know that some people make up stories about themselves all the time. They are described glibly as “pathological liars,” and often come to my attention in the first place because they lie for no apparent reason other than to make themselves more interesting. Recently, for example, a young man went about telling everyone that his girlfriend (he has no girlfriend) committed suicide. The story did not seem designed to reflect positively on him in any way. He was not made out to be a hero. He could not explain to me exactly why he told this story.
Others have lied to me—when I was the Director of a forensic unit—for more obvious reasons. They tried to convince me that they were not guilty of some crime or other because they could not remember what happened, or because they remembered being somewhere else, or because they heard a voice telling them to commit the crime. They expected to gain an advantage in convincing me that something was true, when it was not. I take for granted the fact that people lie to achieve a purpose. But sometimes they lie for no obvious reason.
Some time ago, I saw an adolescent patient who used to go on dating sites on the internet and pretend to be twenty-eight years old. He would makes dates with women and then go to the place of assignation and lurk about in order to watch the women who showed up waiting to meet a man of their age. Similarly, when he was old enough to actually date, he told the girls that he was an American Indian. An American Indian seemed to him to be more dramatic and exciting than being Jewish—although he did not put it to me that way.
Ten years later, this same young man, who was currently in medical school, told me that one of his screen plays was under consideration for production at a major film studio. I congratulated him; but I had the nagging thought that he might not be telling me the truth. It seems everyone (including me) has a screen play tucked away in a drawer with some hope that someday, someone will look at it and want to make it into a big-budget film, making them famous. But that is more an example of patients lying to themselves rather than to their psychiatrist. Currently, I am seeing a tattoo artist whose screen play has drawn attention from some big-name stars, he tells me.
But some stories seem particularly strange. When I was an interne, a woman came to see me with a new-born baby that she was carrying in her arms. She told me that she had taken a nap earlier in the day, and when she woke up, this baby was staring at her from the other end of the couch. She did not know she had been pregnant. She told this story with a straight face. I did not believe her, but I could not figure out why she would manufacture such an account.
When I told this story to an old friend of mine last night—an internist with fifty years’ experience– he said he believed her! He proceeded to tell me of two women he knew who had not realized they were pregnant until they defecated and saw a baby in the toilet. All of these women were very fat.
That led to another discussion. I mentioned a woman physician who was in her early sixties when I knew her. She was, and had been for some time, the Director of Admissions at Grasslands Hospital. She told me that she once examined a couple who were sexually conjoined and could not be separated, like dogs, who have special ligaments in their penis. Dogs can be hooked together uncomfortably until separated. This is the sort of thing that is very amusing to people who are amused by that sort of thing. I believed such a thing could happen to dogs, but not to human beings. I could not figure out why this physician, who was a friend, should tell me such an outlandish story with a straight face. Did she expect me to believe her?
Yet, my friend, the internist, told me that such an untoward event has been reported in human beings. It is called penis captivus. Looking up this condition—which I still think does not exist, any more than the vagina dentate (a vagina with teeth) exists—I discovered that the condition was first described in a hoax by William Osler, a well-known physician. And then repeated in other novels and movies. These are stories told to frighten impressionable young men. Did my friend, the Admissions Director, feel I needed to be forewarned in such a way about such matters?
I had a patient who told me that his identical twin had been obliterated by a piece of falling masonry from the collapsing World Trade Center while he, himself, was walking alongside and was uninjured. Obviously, such a traumatic event would have extraordinary emotional consequences for the surviving twin. Yet, the story was so dramatic, I suspected it might not be true. There were, in fact, 46 sets of twins wherein one of each pair died as the result of that catastrophe; but my patient’s case was not described as one of them. Whatever my suspicions, I always take at face-value any story a patient tells me until I know for certain that it is false. But this was not the sort of story I could put to one side as if it were not relevant to other aspects of my patient’s life. But there was nothing else to do.
So, these are the considerations that weigh in my mind when I hear strange stories:
- Is the story intrinsically very unlikely? (being abducted by space aliens, for instance, or stories of precognition or other psychic events.)
- Does the patient feel so insignificant that there might be some advantage to him/her in dramatizing himself/herself? Does that person relish the power to fool others? Every person, even those who are not liars, takes some pleasure in gossiping—in imparting information that the other person does not know. Plainly, some people find gossiping irresistible—and some simply make up stories
- Does the story reflect badly on the patient? Such stories are more believable. For that reason I believe in the biblical stories of King David. There is virtually no evidence for the existence of the Kingdom of David, but the account of David is so detailed about his transgressions and weaknesses, that they are credible.
- Is the story germane to treatment? If I see someone with “multiple personality,” I pay attention to the ordinary aspects of that person. If the therapist does not get caught up with the exotic aspects of patients’ daydreams, they tend to fade away.
Although I am fascinated by the stories of people’s lives, I try to remind myself that I am there to help patients and not catch them out in fantasies they may wish to tell. (I report other outré sexual anecdotes in “Come One, Come All.”) © Fredric Neuman 2013