“If sanity and insanity exist, how shall we know them?”
Those are the opening words of a classic paper in the history of psychology, David Rosenhan’s famous “pseudopatient” study (pdf), published in the prestigious journal Science in 1973. In his experiment, Rosenhan and seven other people—none of whom had a mental illness—went to 12 different hospitals and complained of “hearing voices.” They explained to hospital staff that the voices said “empty,” “hollow,” and “thud.” They reported no other symptoms.
Surprisingly, all patients were admitted. And even though, upon admission, they denied hearing voices any longer, they all received antipsychotic medication (Rosenhan had instructed his pseudopatients to “cheek” their meds and spit them out later) and were hospitalized for anywhere from 7 to 52 days (average = 19 days). They behaved normally, yet all of their behaviors—for example, writing notes in a notebook—were interpreted by staff as manifestations of their disease. All were discharged with a diagnosis of “schizophrenia in remission.”
Rosenhan’s experiment was a landmark study not only for its elegance and simplicity, but for its remarkable conclusions. Specifically, that psychiatric diagnosis often rests solely upon a patient’s words, and, conversely, that “the normal are not detectably sane.”
Would a similar experiment performed today yield different results? Personally, I think not. (Well, actually, admission to a psychiatric hospital these days is determined more by the availability of beds, a patient’s insurance status, and the patient’s imminent dangerousness to self or others, than by the severity or persistence of the symptoms a patient reports, so maybe we’d be a bit less likely to admit these folks.) At any rate, I’m not so sure that our diagnostic tools are any better today, nearly 40 years later.
In a very controversial book, Opening Skinner’s Box, published in 2003, journalist Lauren Slater claimed to have replicated Rosenhan’s study by visiting nine psychiatric emergency rooms and reporting a single symptom: hearing the word “thud.” She wrote that “almost every time” she was given a diagnosis of psychotic depression and was prescribed a total of 60 antidepressants and 25 antipsychotics (that’s an average of 9.4 medications per visit!). But her report was widely criticized by the scientific community, and Slater even confessed in the November 2005 Journal of Nervous and Mental Disease, that “I never did such a study: it simply does not exist.”
While I’m deeply disturbed by the dishonesty exhibited by Slater, whose words had great power to change the public perception of psychiatry (and I am offended, as a professional, by the attitude she demonstrated in her response to her critics… BTW, if you want a copy of her response—for entertainment purposes only, of course—email me), I think she may have been onto something. In fact, I would invite Slater to repeat her study. For real, this time.
Here’s what I would like Slater to do. Instead of visiting psychiatric ERs, I invite her to schedule appointments with a number of outpatient psychiatrists. I would encourage her to cast a wide net: private, cash-only practices; clinics in academic medical centers; community mental health clinics; and, if accessible, VA and HMO psychiatrists. Perhaps she can visit a few family practice docs or internists, for good measure.
When she arrives for her appointment, she should report one of the following chief complaints: “I feel depressed.” “I’m under too much stress.” “I see shadows out of the corner of my eyes sometimes.” “My mood is constantly going from one extreme to the other, like one minute I’m okay, the next minute I’m all hyper.” “My nerves are shot.” “I feel like lashing out at people sometimes.” “I can’t pay attention at work [or school].” “I sometimes drink [or use drugs] to feel better.” Or anything similar.
She will most certainly be asked some follow-up questions. Maybe some family history. Maybe a mental status exam. She will, most likely, be asked whether she’s suicidal or whether she hears voices. I encourage her to respond honestly, sticking to her initial, vague, symptom, but without reporting anything else significant.
In the vast majority of cases, she will probably receive a diagnosis, most likely an “NOS” diagnosis (NOS = “not otherwise specified,” or psychiatric shorthand for “well, it’s sort of like this disorder, but I’m not sure”). She is also likely to be offered a prescription. Depending on her chief complaint, it may be an antidepressant, an atypical antipsychotic, or a benzodiazepine.
I don’t encourage otherwise healthy people to play games with psychiatrists, and I don’t promote dishonesty in the examination room. I also don’t mean to suggest that all psychiatrists arrive at diagnoses from a single statement. But the reality is that in many practice settings, the tendency is to make a diagnosis and prescribe a drug, even if the doctor is unconvinced of the seriousness of the patient’s reported symptoms. Sometimes the clinic can’t bill for the service without a diagnosis code, or the psychiatrist can’t keep seeing a patient unless he or she is prescribing medication. There’s also the liability that comes with potentially “missing” a diagnosis, even if everything else seems normal.
And on the patient’s side, too, the forces are often in favor of receiving a diagnosis. Sure, there are some patients who report symptoms solely because they seek a Xanax Rx or their Seroquel fix, and other patients who are trying to strengthen a disability case. But an even greater number of patients are frustrated by very real stressors in their lives and/or just trying to make sense out of difficult situations in which they find themselves. For many, it’s a relief to know that one’s troubles can be explained by a psychiatric diagnosis, and that a medication might make at least some aspect of their lives a little easier.
As Rosenhan demonstrated, doctors (and patients, often) see things through lenses that are colored by the diagnostic paradigm. In today’s era, that’s the DSM-IV. But even more so today than in 1973, other factors—like the pharmaceutical industry, the realities of insurance billing, shorter appointment times, and electronic medical records—all encourage us to read much more into a patient’s words and draw conclusions much more rapidly than might be appropriate. It’s just as nonsensical as it was 40 years ago, but, unfortunately, it’s the way psychiatry works.