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
1: Rosenhan DL. On being sane in insane places. Science. 1973
Jan 19;179(4070):250-8. PubMed PMID: 4683124.
2:
Fleischman PR, Israel JV, Burr WA, Hoaken PC, Thaler OF, Zucker HD, Hanley J,
Ostow M, Lieberman LR, Hunter FM, Pinsker H, Blair SM, Reich W, Wiedeman GH,
Pattison EM, Rosenhan DL. Psychiatric diagnosis. Science. 1973
Apr 27;180(4084):356-69. PubMed PMID: 17771687.
3:
Bulmer M. Are pseudo-patient studies justified? J Med Ethics. 1982
Jun;8(2):65-71. PubMed PMID: 7108909; PubMed Central PMCID: PMC1059372.
4:
Spitzer RL, Lilienfeld SO, Miller MB. Rosenhan revisited: the scientific
credibility of Lauren Slater's pseudopatient diagnosis study. J Nerv Ment Dis.
2005 Nov;193(11):734-9. PubMed PMID: 1626092
5: Spitzer RL. More on
pseudoscience in science and the case for psychiatric diagnosis. A critique of
D.L. Rosenhan's "On Being Sane in Insane Places" and "The
Contextual Nature of Psychiatric Diagnosis". Arch
Gen Psychiatry. 1976 Apr;33(4):459-70. PubMed PMID: 938183.
6: Zimmerman M.
Pseudopatient or pseudoscience: a reviewer's perspective. J Nerv Ment Dis. 2005 Nov;193(11):740-2. PubMed
PMID: 16260928.
7:
Inciardi JA, Surratt HL, Cicero TJ, Kurtz SP, Martin SS, Parrino MW. The
"black box" of prescription drug diversion. J Addict Dis. 2009
Oct;28(4):332-47. PubMed PMID: 20155603;
PubMed Central PMCID: PMC2824903.
8: Millon T. Reflections
on Rosenhan's "On being sane in insane places". J
AbnormPsychol. 1975 Oct;84(5):456-61. PubMed PMID: 1194506.
9: Kety SS. From
rationalization to reason. Am J Psychiatry. 1974 Sep;131(9):957-63. PubMed
PMID: 4413516.
