Gary G. Kohls, MD
It is well known that drug-induced mania (and thus a false diagnosis of bipolar disorder “of unknown etiology”) can occur from even standard doses of most psycho-stimulating antidepressant drugs, especially the SSRIs (“selective” serotonin reuptake inhibitors) or during withdrawal from “minor” tranquilizer drugs such as the Valium-type benzodiazepines or “major tranquilizers” such as antipsychotic drugs like Thorazine, Haldol, Risperdal, Zyprexa, Abilify, Seroquel, Geodon, etc.
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In 1973, D. L. Rosenhan published a ground-breaking psychiatric study in January 19 issue of Science magazine. The article exposed a serious short-coming in the psychiatric hospitals at the time, and therefore it became very controversial. Dr. Rosenhan, a professor of psychology and law at Stanford University, designed the study to try to answer the title question: “If sanity and insanity exist, how shall we know them?”
The now famous (some offended or embarrassed psychiatrists preferred to call it “infamous”) experiment that was carried out involved 12 different psychiatric hospitals and 8 different people, mostly professionals (including the author). Each of the eight were totally and certifiably sane “pseudo-patients”.
Each one secretly gained admission to one or two different mental hospitals by falsely complaining to a psychiatrist that they had been hearing voices over the past few weeks. The “voices” in each case were saying only the three words “empty,” “hollow,” and “thud.” No visual hallucinations or other psychological abnormalities were relayed to the examining psychiatrist. Except for the fake “chief complaint”, the intake histories relayed by the patients were entirely truthful. Each “patient” was immediately admitted, much to the surprise of most of the pseudo-patients.
All but one of the admitted “patients” were given a diagnosis of “schizophrenia”. The other one was labeled “manic-depressive”. When they were discharged, the eleven had discharge diagnoses of “schizophrenia, in remission,” despite the fact that absolutely no psychotic or manic behaviors had been observed during their stays.
After admission, each pseudo-patient acted totally sane, each emphasizing that the voices had disappeared. When given the chance, each also asked about when they could be discharged. Those questions were largely ignored by staff.
Despite the fact that each one acted totally normally throughout, their hospital stays averaged 19 days, ranging from 7 to 52 days.
The pseudo-patients engaged in all the normal ward activities except for the fact that they never swallowed the variety of antipsychotic pills that had been prescribed for them. The only obvious difference between the behaviors of the experimental group and the regular patients was that each of them took notes during their hospitalizations. On several occasions, a staff member wrote in the patient’s chart: “the patient engages in note-taking behavior”. Otherwise none of the staff seemed interested in any of the patient’s behaviors.
Although the pseudo-patients planned to secretly smuggle out their daily notes, they eventually stopped trying to hide the fact that they were recording their impressions of their stays, and they soon stopped the smuggling operations – with no consequences.
The average daily contact with the therapeutic staff was only 6.8 minutes per day (mean 3.9 – 25.1 minutes) and that included admissions interviews, ward meetings, group and individual psychotherapy contacts, case conferences and discharge meetings.
The group observed that attendants only came outside the “cage” 11.5 times per 8-hour shift but usually only interacted minimally with the patients when doing so. The staff psychiatrists rarely interacted meaningfully with any patient. If any interaction occurred, it was usually rather patronizing.
None of the professional therapeutic staff ever suspected that any of the 12 were pseudo- patients, whereas many of the “real” patients knew for certain that they were faking. These patients (who were probably actually taking their meds) often said things like: “You’re not crazy. You’re a journalist or a professor. You’re checking up on the hospital.” The staff never tumbled to the subterfuge. The only people who recognized normality were those who themselves had been labeled “insane”.
Upon the publication of the Rosenhan paper, there arose an enormous uproar from the psychiatric community about the “ethics” of performing such a study. Rosenhan was attacked viciously by those who had been fooled or had themselves hastily jumped to erroneous psychiatric diagnoses in the past.
Because of the controversy, Rosenhan announced that there was to be done a follow-up study in a certain research and teaching hospital whose staff had heard about the first study but doubted that such errors could occur in their own hospital. The staff was led to believe that sometime in the next 3 months there would be one or more pseudo-patients attempting to be admitted. However, by design, no pseudo-patients actually attempted admission.
Among the total of 193 patients that were admitted for psychiatric treatment during the 3-month period, 41 genuine patients (20 % of the total) were suspected, with high confidence, of being pseudo-patients by at least one member of the staff. 23 of the 41 were suspected of being fake patients by a psychiatrist, and 19 were suspected by both a psychiatrist and one other staff member. On the bright side, their heightened vigilance saved 41 normal people from receiving a diagnosis of permanent mental illness and the prescribing of brain-altering drugs.
Among the conclusions the reader can draw from these two experiments are these important and quite logical ones:
1) The sane are not “sane” all of the time, nor are those labeled “insane” actually insane all of the time. Definitions of sanity or insanity therefore may often be erroneous.
2) Sanity and insanity have cultural variations. What is viewed as normal in one culture may be seen as quite aberrant in another. As just one example, there was a famous experiment contrasting American and British psychiatrists and each country’s diagnostic differences. The two groups studied identical video-taped interviews of a group of psychiatric patients. In that series of cases, schizophrenia was diagnosed far more often by American psychiatrists than for the British psychiatrists (by a factor of 10, as I recall the article).
3) Bizarre behaviors in people constitute only a small fraction of total behavior. Similarly, violent, even homicidal people are nonviolent most of the time.
4) Psychiatric diagnoses, even those made in error, carry with them personal, legal and social stigmas that can be impossible to shake and which often last a lifetime.
The PPJ Gazette 