By the standards of the American Psychiatric Asociation, 48 million Americans are mentally ill. With the publication of the next - fifth - edition of the APA's bible, Diagnostic and Statistical Manual of Mental Disorders, expected in 2012, it's likely there'll be a whole load more:
The APA isn't just deciding the fate of shopaholics; it's also debating whether overuse of the Internet, "excessive" sexual activity, apathy, and even prolonged bitterness should be viewed, quite seriously, as brain "disorders." If you spend hours online, have sex more frequently than aging psychiatrists, and moan incessantly that the federal government can't account for all its TARP funds, take heed: You may soon be classed among the 48 million Americans the APA already considers mentally ill.
Quite how the association will decide when normal kvetching becomes a sickness—or reasonable amounts of sex become excessive—is still anyone's guess. Behind the APA's doors in Arlington, Va., the fine points of the debate are creating quite a few headaches. And they're also causing a rather public dust-up.
To linger anxiously, even bitterly, over job loss is all too human. To sigh with despair over precipitous declines in one's retirement account is also perfectly understandable. But if the APA includes post-traumatic embitterment disorder in the next edition of its diagnostic bible, it will be because a small group of mental-health professionals believes the public shouldn't dwell on such matters for too long.
That's a sobering thought—enough, perhaps, to make you doubt the wisdom of those updating the new manual. The association has no clear definition of the cutoff between normal and pathological responses to life's letdowns. To those of us following the debates as closely as the association will allow, it's apparent that the DSM revisions have become a train wreck.
If you found yourself locked up against your will in a psychiatric ward, you would probably do your best to get out. But in 1969 a group of people did just the opposite — they tried to get in. A young American psychologist called David Rosenhan persuaded seven friends (two psychologists, a psychiatrist, a doctor, a housewife, a painter and a student) to see whether they could convince doctors that they were mentally ill simply by claiming to hear voices. Now previously unpublished notes from Rosenhan’s private archive reveal what the experience was really like.
Between 1969 and 1972 the team of “pseudo-patients” presented themselves at 12 different US hospitals in five states on the East and West coasts. What would a sane person have to do to convince a doctor they were insane? Not a lot, it seems.
Having claimed to hear words from “thud” and “empty” to “hollow”, words selected because they had never been recorded in psychiatric literature, every pseudo-patient was admitted to hospital for varying lengths of time, from 7 to 52 days. They were given diagnoses of schizophrenia and prescribed a total of 2,100 pills (only two of which were swallowed; in preparation for the study the pseudo-patients had learnt to “cheek” any medication).
Other than giving false names and inventing voices, the patients were to answer all other questions honestly. If they were admitted to hospital they were to say that they felt better and that the voices had disappeared. Not one member of staff suspected them of faking it....
Looking through Rosenhan’s notes, it’s clear that the whole experience has had a lasting effect on him. “Months spent as a pseudo-patient have evoked in me passions that I hardly believed I knew existed,” he says. He found himself in a Catch-22 situation: even when he told the doctors that he felt better, he still wasn’t allowed to leave. “The only way out was to point out that they were correct. They said I had been insane, I was insane, but I was getting better. It was an affirmation of their views.” [...]
The profession reacted furiously, complaining that the fact that they could be tricked did not undermine their methods of diagnosis. It was not their job, they said, to look for hoaxers. Patients could present with fake symptoms in any field of medicine and be prescribed unnecessary treatment. Doctors rely on patients to tell the truth and do not expect them to invent symptoms. After all, a person who goes to his doctor complaining of severe stomach pains would be taken at his word and possibly even admitted to hospital.
But Rosenhan argued that however much psychiatry might want to be viewed like any other branch of medicine, the difference was the lack of further tests to confirm a diagnosis. None of the decisions to diagnose schizophrenia in the pseudopatients was reversed, even for the patient who had been observed for 52 days. Rosenhan wondered how a doctor who could not even tell which patients had mental health problems could ever expect to distinguish between different types of mental illness.
Rosenhan’s friend and colleague, the Stanford University psychologist Lee Ross, believes that he relished the controversy: “I don’t think he minded being attacked. There would be no point in doing the study if he didn’t think he’d get the result he got.” After the study one hospital challenged Rosenhan to send more pseudo-patients, insisting that doctors would be able to spot the fakers if only they knew to look for them. For the next three months they monitored their admissions and uncovered 41 hoaxers. Mischievous as ever, Rosenhan had sent none.
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