In May of this year, the long-awaited fifth edition of the Diagnostic and Statistical Manual (DSM) was published. Like any major change in the field of mental health, the release of the DSM V was not without controversy. Critics argue that many of the revisions are not supported by solid evidence and that inter-rater reliability remains low (i.e., different psychiatrists are likely to diagnose the same patient with different disorders). Furthermore, some have alleged that pharmaceutical companies played too large of a role in the restructuring of the DSM.

It seems that it should be fairly easy to distinguish the mentally healthy from the mentally ill. And yet people, even professionals in the field of mental health, can be surprisingly poor judges of mental illness. This is because mental health is not a static concept – definitions of it may be strongly affected by culturally and individually defined expectations of behavior.

One need only examine the multiple iterations of the DSM to examine how the definitions of illness have changed with cultural norms over the last several decades. For example, until 1974, the DSM listed homosexuality as a sociopathic personality disorder.

But an individual’s expectations may play an even more important part in whether a subject is determined to be well or unwell. The Rosenhan experiment is perhaps the most disturbing example of this. In this experiment, eight pseudopatients made appointments at eight different psychiatric hospitals. They then claimed to be hearing voices that said the words, “empty,” “hollow,” or “thud.” The pseudopatients were all admitted to their respective hospitals. Once admitted, they behaved entirely normally – or at least, how they would behave in everyday life. Not one of the staff members or professionals working with these individuals seemed to notice that the pseudopatients did not belong at the psychiatric ward. In other words, the staff saw what they expected to see; they have been told that these individuals were schizophrenic, and so ignored all evidence (in the form of the patients’ totally normal behavior) to the contrary. Interestingly, nearly 30% of the patients on the ward voiced their opinion that the pseudopatients were not real patients, and were instead journalists or professors.

Many hospitals were somewhat appalled at the results of the Rosenhan experiment and insisted that something like that would never occur in their wards. Rosenhan agreed to test this with one hospital and informed them that they would be receiving at least one pseudopatient over the next three months. Out of the 193 patients that were admitted to the hospital over this period, 41 patients were deemed psuedopatients by at least one staff member and 23 were believed to be pseudopatients by at least one psychiatrist. However, not a single pseudopatient had been sent during this time, further emphasizing the importance of expectation in psychiatric diagnoses.

It should be noted that the Rosenhan experiment was carried out in the early 1970s; some have questioned whether his findings are still relevant. This has yet to be tested, mostly because of the questionable ethics of pseudopatient studies. Whether or not psychiatric wards are still so governed by expectations, Rosenhan’s experiments still raise interesting questions about psychiatric labels. Once someone has been diagnosed with a mental illness, there is often very little they can do to overcome this label. Furthermore, this label strongly affects how others behave toward the individual. We should carefully consider how we label patients and delve deeper into how these labels may affect their recovery.

Sources

Bulmer, M. (1982). Are pseudo-patient studies justified? Journal of Medical Ethics, 8(2): 65-71.

Frances, A. (2013). The past, present, and future of psychiatric diagnosis. World Psychiatry, 12(2): 111-112.

Rosenhan, D.L. (1973). On being sane in insane places. Science, 179(4070): 250-258.