Every now and again the detractors and critics of psychiatry like to march out the results of an old study as "proof" of the lack of validity of psychiatric diagnoses. In that study, 8 pseudopatients feigned mental illness to gain admission to 12 different psychiatric hospitals. The conclusion of the study author was widely seen as having significant impact on the profession, but that conclusion seems to have been largely retrospective. I started my training about a decade later and there were no residuals at that time. I learned about the study largely through the work of antipsychiatrists and psychiatric critics.
Several obvious questions are never asked or answered by the promoters of this test as an adequate paradigm. The first and most obvious one is why this has not been done in other fields of medicine. It would certainly be easy to do. I could easily walk into any emergency department in the US and get admitted to a Medicine or Surgical service with a faked diagnosis. I know this for a fact, because one of the roles of consulting psychiatrists to Medicine and Surgery services is to confront the people who have faked illness in order to be admitted. Kety (9) uses a more blunt example in response to the original pseudopatient experiment (1):
"If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition. "(9)
I also know that this happens because of the current epidemic of prescription opiate abuse and the problem of drug seeking and being successful at it. An estimated 39% of diverted drugs (7) come from "doctor shopping." By definition that involves presenting yourself to a physician in a way to get additional medications. In the case of prescription opioids that usually means either faking a pain disorder or misrepresenting pain severity. So it is well established that medical and surgical illness well outside of the purview of psychiatry can be faked. And yet to my knowledge, there is hardly any research on this topic and nobody is suggesting that medical diagnoses don't exist because they can be faked. Does that mean the researchers consider the time of these other doctors too valuable to waste? More likely it did not fit a preset research agenda.
The second obvious question has to do with conflict of interest. It is currently in vogue to suggest that psychiatrists are swayed in their prescribing practices by incentives ranging from a free pen to a free meal. Compensation as a company employee or to give lectures is also thought of as a compromising incentive. The free pen/free meal incentive is pretty much historical at this time. What about intentionally misrepresenting yourself? What is the conflict of interest involved at that level and how neutral can you stay when you are trying to escape detection in order to prove a point? A vague script like a mono-symptomatic presentation of schizophrenia should suggest that the intent is to escape detection. How should a person with a vague script act when they are face to face with a real clinician? The logical conclusion is that they would be as evasive as possible even if they were adhering to that protocol.
The bottom line is that the pseudopatient experiments were seriously flawed out of the box. Continuing to promote them as meaningful reflects a serious lack of scholarship in reading the relevant literature and a need to suspend the reality that in fact mental illness does exist, that distinctions can be made among various types of mental illness, and that those distinctions are useful to psychiatrists trying to help people with those problems.
George Dawson, MD, DFAPA
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