Day 913: Psychiatric Pseudo-Symptoms Take Aim At Science

originally published July 1, 2014

In more than one of his couch-quivering rants, Tom Cruise has expressed distrust and disdain for the science of psychiatry. Perhaps he believes Xenu and his intergalactic pals can do more for the struggling mind than can a branch of human medicine. I don’t agree – and I count that as a big win for my own sense of logic and reason. The science isn’t perfect but it’s progressing, and while the humans who administer its teachings are fallible, there’s still actual science there.

Psychologist and Stanford professor David Rosenhan also found the whole thing suspicious. It was the early 1970’s and psychiatric patients were treated somewhat differently than they are today, as anyone who read Ken Kesey’s One Flew Over The Cuckoo’s Nest will know. Doc Rosenhan wasn’t convinced that patients were being properly diagnosed, and he wasn’t sold on the standard treatment procedure either. He came up with a devious plan.

What if someone perfectly sane were to talk their way into a psychiatric hospital, only to have their symptoms disappear once inside? What ensued was a damning criticism of psychiatry and psychiatric diagnosis, one which still resonates to this day. But was Doc Rosenhan’s experiment a genuine scalpel-slice through the pristine flesh of the science of mental health, or was it pseudoscience? His results were shocking, but in fact they need to be scrutinized beyond the knee-jerk swoop of an accusatory finger.

Doc Rosenhan drafted eight ‘pseudo-patients’ for his experiment, which included himself, a grad student, two other psychologists, a pediatrician, a psychiatrist, a painter and a housewife. The eight of them were to show up at ten different psychiatric hospitals around the country. Underfunded rural hospitals were targeted, as were revered urban university hospitals and one pricey private hospital. Everyone held true to their biographical details, apart from their names (which were changed to protect them) and in the case of those who were actually in the medical field, their occupations. Doc Rosenhan didn’t want any special treatment for anyone.

The symptoms were all to be the same: auditory hallucinations of a voice with the same gender as the pseudo-patient. The voices were garbled and unclear, but sounded as though they were pronouncing words like ‘empty’, ‘hollow’ and ‘thud’. Those words were chosen because while they vaguely hinted at a possible existential crisis, but none of the words had been documented in any published work as relating to psychotic symptoms. The pseudo-patients were to complain of no other issues.

The results were unsettling. Despite the fact that the pseudo-patients had been instructed by Doc Rosenhan to behave completely normally as soon as they were admitted (even the ‘voices’ were to mysteriously stop), seven of them were diagnosed with schizophrenia, and one with manic-depressive psychosis. The pricey private hospital offered a more optimistic diagnosis. The patients were viewed through the lens of a schizophrenic patient – their normal behaviors, such as taking written notes (as Doc Rosenhan had instructed them to do), were viewed as pathological writing behavior, or some other disorder.

The patients’ release was part of the experiment. With no additional hallucinations, and no other symptoms of any kind, it was expected they’d all be sent home fairly quickly. It actually took between 7 and 52 days for the patients to see freedom, and in all that time not a single doctor, nurse or staff member observed that the patients were imposters (though it should be noted that a number of the other patients did clue in). Many were given antipsychotic meds (which they flushed) and when they were all discharged, they were labeled as schizophrenic, but in remission.

Where this experiment and/or effort to show up the field of psychiatry as being flimsy and inaccurate falls short is with the obvious demonstration of dishonesty on the part of the pseudo-patients. Once admitted, each patient is going to be treated based on the symptoms they’d sworn had been present just a day or a few days before. In much the same way, I could hobble into my doctor’s office complaining of an aching back, and even though the X-ray would show nothing physically wrong, he would believe I was hurting and he’d treat me thusly.

In issuing their final diagnoses, the hospital staff would likely be hesitant to scribble a sparkly clean bill of mental health, especially since this patient was hearing voices just a couple weeks earlier. The staff is not looking for an imposter; medical imposters are generally playing their shtick because they’re after pills or some other reward. Also, it helps that the pseudo-patients never had to pretend to hear those voices in the presence of any medical professional. The symptoms had “mysteriously stopped”, so as far as the staff was concerned, there was no reason to assume fakery.

In short, this is a highly imperfect experiment.

Where the experiment really hit home was when the pseudo-patients reported on the conditions within the various facilities. Ken Kesey was not far off in his novel; patients were not being treated with the utmost care in these places. All pseudo-patients reported an air of dehumanization, in which the staff treated those in their keep like objects. They spoke about the patients as if they weren’t in the room, and were often verbally and physically abusive to them. Doctors actually interacted with each patient for an average of only 6.8 minutes per day.

The patients’ belongings were randomly searched, and at times they were watched while using the toilet. That seems like an odd requirement for someone who had merely been complaining about some audible hallucinations, but for whatever reason, it happened. Doc Rosenhan’s experiment may not have effectively discredited the psychiatric profession (even a little), but it did reveal some poor practices by medical personnel, and likely helped to expedite the reevaluation and reform of American mental institutions.

Doc Rosenhan had one more experiment to try out before his results were published in Science magazine.

A well-respected hospital had heard of Doc Rosenhan’s results, and claimed outright that such errors in diagnosis could not possibly happen within the hallowed walls of their fine, upstanding institution. Doc Rosenhan called their bluff. He told them that during a three-month term he would be sending one or more pseudo-patients to their hospital to gain admission, and their staff would have to identify them. Out of 193 patients who were admitted to that hospital during the specified time-frame, 41 were considered to be imposters and 42 others were considered suspect. So how many did they get right?

Zero.

Doc Rosenhan had cranked up their paranoia meter, all while sending a whopping zero pseudo-patients to be admitted. “Any diagnostic process that lends itself too readily to massive errors of this sort,” Doc Rosenhan concluded, “cannot be a very reliable one.” He has a point. It’s also notable that there was a tremendous reduction in the number of admissions to that hospital during this time-frame, which suggests that they’d been letting in far too many patients before knowing their staff and diagnoses would be under scrutiny.

Any good experiment needs to be repeated with identical results before it can be accepted as good science, and to my knowledge no one else has conducted a similarly wide sweep of the system in this manner. But I’d be curious to see how much farther the field of psychiatry has truly come.