'The Great Pretender' by Susanah Cahalan

Anyone who has an interest in mental illness, how it is diagnosed and treated, and especially an interest in society’s attitude to psychiatric practice will enjoy this book. It concerns the study published in Science in 1973 called “On being sane in insane places” by David Rosenhan, then professor of Psychology and Law at Stanford University. In summary this study purported to report on the fates of eight pseudo-patients who presented to psychiatric hospital. They reported hearing auditory hallucinations of a word such as “Thud” or a phrase such as “its hollow inside“. After this report, they behaved entirely normally without feigning any symptoms or exhibiting any unusual behaviour. The study reported that they were all admitted and diagnosed as mentally unwell (usually as having schizophrenia) and during weeks of admission given treatment for these conditions. The study suggested that psychiatrists could not distinguish between the sane and the insane, between health and mental illness.

This study shook psychiatry and mental health services to their core. At the time, following the work of the likes of Thomas Szasz (‘The Myth of Mental Illness’) and Erving Goffman (‘Asylums’), this seemed to give support and credence to the anti-psychiatry movement and provoked widespread, comprehensive and much needed change into the provision of in-patient psychiatric services. It was probably one of the prime drivers for the development of the DSM-III system of diagnosis which, at the time, helped address some of the major failings of psychiatric diagnosis.

I recall when I was a lecturer in psychological medicine referring to this study when lecturing to medical undergraduates, or psychiatric postgraduates, to try and inculcate a sense of shame that the profession was able to perform so poorly and fail our patients so badly.As a simple study with a blindingly obvious outcome it was very valuable.

However, it seems I may have been wrong. Without giving too much away this book looks into the study and checks the veracity of the reports. The author had a personal experience of psychiatric mis-diagnosis when she fell ill with autoimmune encephalitis and presented with psychotic symptoms. This kindled, in her, an interest in diagnostic accuracy and the interface between mental and physical illness and prompted her to look at this landmark study. Early in her research she noted significant defects in the study which she then started to explore. As the author follows clues, leading to the uncovering major flaws in the study, this book reads as easily as detective fiction. Although I suppose I should really class it as a true crime drama.

There is clear evidence that the ‘facts’ as reported are not the fact as they occurred. It is clear that some pseudo-patients actively feigned mental illness and threatened self-harm to capture the psychiatrists’ attention. The reports were also selectively reported so that positive or helpful experiences of psychiatric care were deliberately omitted from the published report. There is some, equivocal, evidence that Rosenhan was actively fraudulent in creating stories out of thin air to support his theories.

It is sad when our heroes turn out to have feet of clay. We feel duped when we discover the facts that were presented to us, and which we acted on, were misleading. However, many of the changes that followed this study were needed and one could argue that a “good lie” was more effective than many dry studies in forcing a change in the psychiatric services. I still hope that when people read the study they will think “how can we avoid problems like that ?“. However, a ‘good lie’ may prompt change but it is not a useful compass for what direction that change should take. We will all be glad to see that some of the bad practices are gone but this study did not help us see the positive aspects of “asylum” nor how we can preserve these. It lead us to throw the baby out with the bath water.

It is true that there are many less in-patient beds for patients with mental illness and that hospitals no longer degrade patients as they did. However, we now have many more psychiatric patients in prisons, nursing homes and general medical wards. Often the care here is poorer than that of the old institutions and I fear that the many mentally ill patients trapped in prisons are experiencing degrading and unpleasant treatment the equal of that in a seventies mental health hospital. In some senses we have just changed the nurse into a prison warder and the locked ward into a prison cell – the place and person may have changed but the crime hasn’t.

To improve the treatment of the mentally ill we need not only to understand mental illness better but also to understand better our own attitudes towards it. Although I will miss using this study in a ‘fire and brimstone’ talk about diagnostic accuracy I would (were I still teaching) have to be very cautious referring to it now. When we think we understand, but don’t, we are at the greatest risk of making mistakes. As this book reveals, even with good intentions, a prejudiced and dishonest look at the facts helps no-one in the long run.

I used to be clumsy but I’m dyspraxic now.

via Daily Prompt: Clumsy

straightjacketOne of the trends of recent years has been the increasing medicalisation of our lives. Issues that previously were thought of as aspects of our personality or experience are viewed the rough the lens of health care. This trend has a long and venerable heritage. When Hippocrates wrote “On the Sacred Illness” and proposed fits, due to epilepsy,  were due to phlegm from the brain rather then a punishment form the Gods, this was a major scientific advance.In the middle ages the recognition of some forms of mental illness as diseases rather then proof of demonic possession save some unfortunates from the rack and the stake.  Shifting behaviours due to disease into the medical arena has been, without doubt, beneficial.

As our scientific knowledge increased  more and more conditions were recognised for what they were. Times when people might have been thought to be lazy and slothful (when they had anaemia, renal failure, and so on) are gone and it is recognised that these people in fact suffered from disease or illness. They are taken out of the social realm and placed in the medical realm and thus  excused from normal social responsibilities – we do not expect the lame or blind to work the same as others, we accept that those with schizophrenia may at times behaviour oddly or even rudely. This reduction of our responsibilities is beneficial as we are not then punished for behaviours not under our control.

However, this has not always been a change for good. In the nineteenth centuary a medical disorder of drapetomania was proposed by the American physician Samuel A. Cartwright. The essence of this condition was the desire to escape captivity and servitude; the ‘treatment’ was regular whipping to deter slaves from running away. More recently the KGB in the USSR worked with doctors, using the diagnosis of “sluggish schizophrenia” to incarcerate many dissents in mental hospitals. They used the diagnostic label to undermine the behaviours of political dissenters by making them symptoms of medical disorders there was no need to pay any heed to them – disagreement became madness.

It is with this in mind that recent changes concern me. There has been a tendency to identify difference as disorder. The socially awkward man with a liking for habit and routine becomes a man with Asberger’s Syndrome, the clumsy child becomes a patient with ‘dyspraxia’, the shy become ‘socially phobic’, the sad and disappointed become people with ‘minor depressive disorders’, and so on. There is a preoccupation with illness and an acceptance that it is almost universal we all have some disorder !

But this is a dangerous path. Placing people in the role of being ‘unwell’ has a number of risks. These might be outweighed by advantages as mentioned above, such as excusing us from our normal social responsibilities, or giving an explanation of our behaviour, or offering some form of treatment to improve our lot. But recent expansions of the ‘sick role’ seem to offer none of these. Someone who is clumsy knows no more about the origins of their clumsiness after the label of ‘dyspraxic disorder’ has been applied, they knew that their brain was less good than the average in motor tasks and dexterity already. We know no more about the socially awkward obsessive after we have labelled him as having Asberger’s syndrome, we have gained no new insights about him.

None of these, and many other disorders, have, at present, any treatments available for them. The steps one might take to mitigate against their signs and “symptoms” are common sense. Importantly, the steps which might help are not known only to medical professionals  they are things we can all work out. Thinking that these disorders are some form of illness or disease limits the sources of help people may receive. People may undervalue the advice of the non-professional and miss possibly useful assistance form their friends, family or themselves.

The exclusion from social responsibility is a double edged sword. While people may feel some relief following being  labelled as having some disorder and may benefit that others expect less of them – “I have X disorder, you can’t expect me to do Y” – what if the person want to be able to “do Y” ? The urge to overcome differences, that are seen as a disadvantage, might be suppressed. The socially phobic might not press themselves to gradually expand their repertoire of social activities and thus lead a smaller, less rewarding life than they may have been able to do otherwise.

Worse that curtailing the individual’s attempts to improve their lot is the danger that, now in the arena of healthcare, physicians will try and improve them. Already millions of unnecessary  and ineffective prescriptions for medication are given to the mildly depressed or socially anxious (as well as many other dubious ‘disorders’). Each time such a pill is swallowed someone takes a risk of harm without the prospect of any benefit. It is true to say that some people die as a consequence of  saying “I have disorder X” as opposed to accepting “this is the way I am

Society as whole also looses out by this trend. Every time a deviation from the norm is categorised as a disorder we reduce what we consider the range of normal human life. We restrict the range of what is acceptable. While, in our present humane and liberal democracies, this may not be too risky there is no guarantee that this will always be the case.

Illness, ill-health and disorder are the exception we should fight to make sure that they remain so.


Written in response to the daily prompt : Clumsy