criticism of rosenhan experiment

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• 29 October 2019

On the troubling trail of psychiatry’s pseudopatients stunt

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The Great Pretender: The Undercover Mission that Changed our Understanding of Madness Susannah Cahalan Grand Central Publishing (2019)

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Nature 574 , 622-623 (2019)

doi: https://doi.org/10.1038/d41586-019-03268-y

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Rosenhan (1973) Experiment – ‘On being sane in insane places’

Angel E. Navidad

Philosophy Expert

B.A. Philosophy, Harvard University

Angel Navidad is an undergraduate at Harvard University, concentrating in Philosophy. He will graduate in May of 2025, and thereon pursue graduate study in history, or enter the civil service.

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Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

Key Takeaways

• Between 1969 and 1972, Prof. David Rosenhan, a psychiatrist at Stanford University, sent eight pseudo-patients to 12 psychiatric hospitals without revealing this to the staff. None of the pseudo-patients had any symptoms or history of mental disorders.
• In all 12 instances, pseudo-patients were diagnosed with a mental disorder and hospitalized. In no instance was the misdiagnosis discovered during hospitalization.
• In some of the 12 hospital stays, pseudo-patients observed significant deficits in patient-staff contact.
• In a follow-up study at one hospital, Prof. Rosenhan asked staff to rate patients seeking admission on a 10-point scale, from “highly likely to be a (healthy) pseudo-patient” (1 or 2) to “least likely to be a pseudo-patient.” Staff were aware of the previous study and told one or more pseudo-patients would be sent their way unannounced. Forty-one (21.24%) of 193 patients received a 1 or 2 score. No pseudo-patients were, in fact, sent.
• These findings provided convincing evidence against the accuracy and validity of psychiatric diagnoses.
• The current state of psychiatric diagnoses is still broadly at odds with recent neurological findings, leading to uncertainty regarding their accuracy. Several interventions are proposed or underway to correct this. None counts with widespread support yet.

In the years leading to 1973, professor of law and psychology at Stanford University, Mr. David L. Rosenhan, sought to investigate whether psychiatrists actually managed to tease normal and abnormal psychological states apart. As Prof. Rosenhan put it:

At its heart, the question of whether the sane can be distinguished from the insane (and whether degrees of insanity can be distinguished from each other) is a simple matter: do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them? Rosenhan 1973, p. 251.

The recent publication of the APA’s DSM II in 1968 underscored the popular belief among practitioners that psychiatric conditions could be distinguished from each other and from normal psychiatric good health, much like physiological diseases can be distinguished from each other and from good health itself.

In the 1960s, an increasing number of critiques of this belief emerged, arguing that psychiatric diagnoses were not as objective, valid, or substantive as their physiological counterparts, but were rather more like opinions and, therefore, subject to implicit biases even when propounded by competent psychiatrists or psychologists.

Prof. Rosenhan set out to settle the matter empirically. He resolved to have people with no current or past symptoms of serious psychiatric disorders admitted to psychiatric hospitals.

If their lack of abnormal psychiatric traits were always detected, he reasoned, we would have good evidence that psychiatrists were able to tell normal from abnormal psychiatric states. Psychiatric normality, it was presumed, was distinct enough from abnormality to be readily recognized by competent practitioners.

Nine participants, including Prof. Rosenhan, were recruited. All were deemed to have no present or past symptoms of serious psychiatric disorders. Each gained admission to one of nine distinct hospitals.

In eight cases, admittance was gained without the hospital’s staff’s foreknowledge.

In Prof. Rosenhan’s case, the hospital administrator and chief psychologist knew of their hospital’s inclusion in the study. Data from Prof. Rosehan’s stay or stays were not excluded.

Data from one participant were excluded due to a protocol breach (falsification of personal history beyond that of name, occupation, and employment). Between one and four of the remaining eight participants thereafter gained further admission to four other hospitals.

Data from 12 hospital stays, at 12 different hospitals, by eight participants were included in the study. Five of the included participants were male adults; three were female adults. Five worked or were engaged in psychology or psychiatry.

One of the 12 hospitals was privately funded; the rest received public funding. An undisclosed number of hospitals were “old and shabby” or “quite understaffed.”

The 12 hospitals were located in five states in the East and West coasts of the US.

The admittance, stay, and discharge process was as follows —

• Participants set up an appointment at one of the hospitals under a false name, occupation, and employment.
• At the appointment, participants complained they had been hearing unfamiliar, often unclear voices which seemed to come from someone of their own sex and which seemed to say “empty,” “hollow,” and “thud;” participants provided truthful information on all matters other than name, occupation, and employment, with names, occupations and employment information of friends and family changed to fit with the participant’s assumed name, occupation, and employment.
• On admittance, participants stopped simulating any psychiatric symptoms, though there were a few cases of “brief[,] … mild nervousness and anxiety” which “abated rapidly.”
• In psychiatric wards, participants engaged with patients and staff as they would normally with colleagues in everyday life. When asked by staff how they were feeling, participants indicated that they were fine and that they no longer experienced symptoms. They received but did not ingest their prescribed medication, except in one or two instances. They recorded their observations regarding the ward, staff, and patients.
• Participants were discharged when the hospital’s staff responsible for their stay saw fit. A writ of habeas corpus was kept on file for each participant an undisclosed number of days after the study began.
• Between one and four participants repeated this process at four other hospitals.

Two further protocol breaches, which did not result in exclusion, were reported. One participant revealed their occupation in psychology to staff members. Another “attempted a romance with a nurse,” revealed their occupation in psychology to staff members, and provided psychotherapy to fellow patients.

Nursing reports for an undisclosed (“most”) number of the 12 stays were obtained from the hospitals. Coding protocols and training were not reported.

Depersonalization Observations

At four of the 12 hospitals, staff responses to patient-initiated contact were also investigated.

During their stay, four participants approached staff members with a request of the form, “Pardon me, Mr. [or Dr. or Mrs.] X, could you tell me when I will be eligible for grounds privileges?” or “… when I will be presented at the staff meeting?” or “… when I am likely to be discharged?”

No staff member was approached more than once a day. Staff responses were recorded.

Criteria for response classification, recording protocols, and pre-study training were not disclosed.

At six of the 12 hospitals, patients’ daily contact with staff (in minutes), from the initial admission interview to the final discharge meeting, inclusive of both, was measured.

Measurement protocol and pre-study training were not disclosed.

Non-existent Imposter Study

A second study was arranged at a research and teaching hospital in an undisclosed location. Its staff were aware of the first study’s results.

They were informed that one or more persons, previously instructed to simulate at least one symptom of a psychiatric disorder, i.e., a pseudo-patient, would attempt to gain admission within the following three months.

Staff were asked to rate each patient seeking admission on a ten-point scale, from most likely to be a pseudo-patient (1 or 2 on the scale) to least likely. No participants were, in fact, sent to the hospital. Scores were obtained for 193 patients.

No patients were independently evaluated by Prof. Rosenhan or affiliated researchers. No scoring protocol nor pre-study training was reported.

In eleven instances, participants were admitted on a diagnosis of schizophrenia and discharged with a diagnosis of schizophrenia in remission.

In one instance, a participant was admitted on a diagnosis of manic-depressive psychosis; their discharge diagnosis was not reported. Stays ranged from 7 to 52 days, with a mean of 19 days. Standard deviation was not disclosed.

Nursing reports “uniformly indicate[d] that the [participants] were “friendly,” “cooperative,” and “exhibited no abnormal indications.” Coding results and statistical significance were not reported.

Participants’ visitors “could detect no serious behavioral consequences [of hospitalization in participants].” No information on data collection from said visitors, nor statistical analyses on these data, were reported.

The errant diagnosis on admission, Prof. Rosenhan noted, could simply be attributed to physicians’ strong bias towards type II errors. As he put it:

The reasons [for this strong bias] are not hard to find: it is clearly [less] dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy. Rosenhan 1973, p. 252

Errant diagnoses after admission, once participants had dropped all pretense of psychiatric disturbance, were more surprising and troubling to Prof. Rosenhan.

It seemed that once diagnosed with an aberrant psychiatric trait, participants were unable to escape the diagnosis, despite their having dropped the farce immediately upon admission.

It was presumed that a competent practitioner, upon being well-acquainted with participants, would eventually identify the initial diagnosis as a type II error  and subsequently correct it. No such correction took place in any of the 12 hospital stays.

The admission diagnoses seemed, in Prof. Rosenhan’s words, “so powerful that many of the [participants’] normal behaviors were overlooked entirely or profoundly misinterpreted.”

Prof. Rosenhan offered the following explanation for this surprising result. Persons not diagnosed with a mental illness, nonetheless, at times, exhibit “aberrant” behavior, like pacing around or frequently writing. Without a psychopathic diagnosis, these behaviors are attributed to something other than psychopathy, like being bored or being a writer.

But in the presence of such a diagnosis, these behaviors are more often attributed to psychopathy, as they were in two instances in the study than not. This attribution, in turn, only reinforces the diagnosis, thereby fixing any type II errors in place.

The fact that such behaviors are often attributed to psychopathies in diagnosed patients, Prof. Rosenhan argued, points more to the “enormous overlap in behaviors of the sane and the insane” than to the competence of psychiatrists, psychologists, or nurses.

On initiating contact with staff members, participants were overwhelmingly not paid any attention by psychiatrists, nurses, or attendants at four of the hospitals. Inter-hospital differences were not deemed significant and were not reported. Statistical differences and significance were not reported.

Six participants, totaling 129 days of hospitalization, measured their daily contact with staff. Daily contact with psychiatrists, psychologists, residents, and physicians ranged from 3.9 to 25.1 minutes, with a mean of 6.8 minutes. Disaggregated data, contact time with other staff, statistical differences, statistical significance, and standard deviation were not reported.

Contact, Prof. Rosenhan notes, indicates “concern and individuation,” its lack, “avoidance and depersonalization.” Staff’s overwhelming avoidance of patients, Prof.

Table 1. Self-initiated contact by participants with psychiatrists, nurses, and attendants. Adapted from Table 1 of the 1973 Rosenhan study, p. 255. Copyright (c) 1973 AAAS.

Rosenhan notes resulted in an “overwhelming sense of powerlessness which invades the individual as he is continually exposed to the depersonalization of the psychiatric hospital.”

The import of this practice, and the powerlessness it elicited, Prof. Rosenhan argued, could be readily inferred.

[H]ow many patients might be “sane” outside the psychiatric hospital but seem insane in it_—not because craziness resides in them, as it were, but because they are responding to a bizarre setting … ? — Rosenhan 1973, p. 257

Of the 193 scores obtained, 41 patients were judged highly likely to have been a pseudo-patient by at least one staff member, 23 by at least one psychiatrist, and 19 by one psychiatrist and at least one other staff member. No pseudo-patients were sent by Prof. Rosenhan or affiliated researchers.

Of the 41 patients judged highly likely to have been pseudo-patients —

• Either they did not, in fact, have any abnormal psychiatric symptoms and were correctly judged pseudo-patients by the staff;
• Or they did, in fact, have abnormal psychiatric symptoms (as presumed by the fact that they wished to be admitted), in which case the staff misdiagnosed them as pseudo-patients and thereby made a type I error in seeking to avoid type II errors.

In either case, Prof. Rosenhan pointed out the results indicated “that the tendency to designate sane people as insane can be reversed when the stakes (in this case, prestige and diagnostic acumen) are high.”

But it is notable that, in the second case, the price for avoiding type II errors might just be a higher type I error rate.

It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meanings of behaviour can easily be misunderstood. Rosenhan 1973, p. 257

Both practitioners and patients, the study reveals, seem caught in Catch-22s. Out of an excess of caution, psychiatrists and psychologists strongly tend towards type II errors on admission. But once said error is made, there’s a slim chance it will be caught during in-patient treatment.

On the other hand, should practitioners try to avoid type II errors from sticking to patients, they run the risk of equally damaging type I errors. On the other hand, patients, once admitted, are likely to develop psychopathies, whether they truly had any on admission or not, given the bizarre setting they are thrust into on admittance.

But should they seek to avoid the setting — the psychiatric hospital — they run the risk of an untreated mental illness getting worse, in the case they truly suffered one, to begin with.

A way out for practitioners and patients is not immediately clear to Prof. Rosenhan. Two promising directions he noted were —

• The avoidance of psychiatric diagnoses of the form encouraged by the DSM II in favor of diagnosing patients with “specific problems and behaviors” so as to provide treatment outside of psychiatric hospitals and to keep any diagnostic label from “sticking” to a patient;
• Increasing “the sensitivity of mental health workers and researchers to the Catch-22 position of psychiatric patients,” for e.g., by having them read pertinent literature.

Other Conclusions

A good number of the study’s shortcomings should give us pause when drawing conclusions. Sampling, randomization, control, blinding, and statistical analysis methods were largely unreported and so likely not to have been up to present-day standards.

Participant training was not reported and so likely not undertaken before the study. No data on participants’ visitors and their evaluations were reported.

Study flaws aside, the observed effects were large enough to likely be clinically, and easily statistically, significant —

• All 12 hospitalizations resulted in type II errors both on admission and discharge;
• 2.94% of the 1,468 recorded participant-initiated interactions with psychiatric staff resulted in verbal engagement with the participant;
• 9.84% of the 193 patients scored at a research and teaching hospital were deemed very likely to have had no psychopathic traits on admission by both a psychiatrist and at least one other staff member.

The findings pointed to an unacceptable preponderance and persistence of type II errors by competent psychiatric staff and to the danger of psychiatric harm to patients posed by then-current psychiatric practices.

Critical Evaluation

Was the sample representative.

Field experiments have the major advantage of being conducted in a real environment and this gives the research high ecological validity. However, it is not possible to have as many controls in place as would be possible in a laboratory experiment.

Participant observation allows the collection of highly detailed data without the problem of demand characteristics. As the hospitals did not know of the existence of the pseudopatients, there is no possibility that the staff could have changed their behavior because they knew they were being observed.

However, this does raise serious ethical issues (see below) and there is also the possibility that the presence of the pseudopatient would change the environment in which they are observing.

Strictly speaking, the sample is the twelve hospitals that were studied. Rosenhan ensured that this included a range of old and new institutions as well as those with different sources of funding.

The results revealed little differences between the hospitals. This suggests that it is probably reasonable to generalize from this sample and suggest that the same results would be found in other hospitals.

Prof. Rosenhan’s 1973 paper does not detail —

• How his sample size was determined, nor how his sample was selected;
• The study’s inclusion/exclusion criteria;
• How past or present serious psychiatric symptoms were diagnosed, nor by whom;
• Whether past or present mild to moderate psychiatric symptoms were diagnosed, nor by whom;
• How hospitals were selected;
• How participants were matched with false names, occupations, and employment information;
• How participants were matched with hospitals.

What type of data was collected in this study?

There is a huge variety of data reported in this study, ranging from quantitative data detailing how many days each pseudopatient spent in the hospital and how many times pseudopatients were ignored by staff to qualitative descriptions of the experiences of the pseudopatients.

One of the strengths of this study could be seen as the wealth of data that is reported and there is no doubt that the conclusions reached by Rosenhan are well illustrated by the qualitative data that he has included.

Was the study ethical?

Strictly speaking, no. The staff were deceived as they did not know that they were being observed and you need to consider how they might have felt when they discovered the research had taken place.

Was the study justified? This is more difficult as there is certainly no other way that the study could have been conducted and you need to consider whether the results justified the deception. This is discussed later under the heading of usefulness.

What does the study tell us about individual/situational explanations of behavior?

The study suggests that once the patients were labeled, the label stuck. Everything they did or said was interpreted as typical of a schizophrenic (or manic-depressive) patient. This means that the situation that the pseudopatients were in had a powerful impact on the way that they were judged.

The hospital staff was not able to perceive the pseudopatients in isolation from their label and the fact that they were in a psychiatric hospital, and this raises serious doubts about the reliability and validity of the psychiatric diagnosis.

What does the study tell us about reinforcement and social control?

The implications of the study are that patients in psychiatric hospitals are ‘conditioned’ to behave in certain ways by the environments that they find themselves in.

Their behavior is shaped by the environment (nurses assume that signs of boredom are signs of anxiety, for example) and if the environment does not allow them to display ‘normal’ behavior, it will be difficult for them to be seen as normal.

Labeling is a powerful form of social control. Once a label has been applied to an individual, everything they do or say will be interpreted in the light of this label.

Rosenhan describes pseudopatients going to flush their medication down the toilet and finding pills already there. This would suggest that so long as the patients were not causing anyone any trouble, very few checks were made.

Was the study useful?

The study was certainly useful in highlighting the ways in which hospital staff interact with patients. There are many suggestions for improved hospital care/staff training that could be made after reading this study.

However, it is possible to question some of Rosenhan’s conclusions. If you went to the doctor falsely complaining of severe pains in the region of your appendix and the doctor admitted you to the hospital, you could hardly blame the doctor for making a faulty diagnosis.

Isn’t it better for psychiatrists to err on the side of caution and admit someone who is not really mentally ill than to send away someone who might be genuinely suffering?

This does not entirely excuse the length of time that some pseudopatients spent in the hospital acting perfectly normally, but it does go some way to supporting the actions of those making the initial diagnosis.

Outlook of Diagnostic Accuracy

Psychiatric diagnoses continue to be made as they were at the time of Prof. Rosenhan’s study — largely on the basis of inferences drawn from patient self-reports and practitioners’ observations of patient behavior and largely on the basis of criteria set by the APA’s DSM. This suggests two sources of diagnostic problems in psychiatry —

• the evidence used to reach a diagnosis, and
• the criteria by which said evidence is evaluated in reaching a diagnosis.

The evidence available to psychiatrists and psychologists in diagnosing mental disorders has long been much sparser than that available to other physicians.

There have been advances in the etiology of mental disorders — the relevant MeSH term now counts over 370,000 articles in PubMed, 4.00% of which are RCTs, meta-analyses, or systematic reviews.  This growing corpus has yet to yield diagnostic tests, though.

In 2012, a group of three psychiatrists, led by Prof. Shitij Kapur of King’s College London, argued that a number of reasons were responsible for this lag, including widespread methodological shortcomings and the DSM’s classification itself.

On that note, the DSM has left much to desire. As Mr. Thomas Insel, former director of the NIMH, put it —

Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. Insel 2013, second para.

Since its first publication in 1958, the DSM has reached a classification of mental disorders without data on their biological underpinnings.

Its nosology is increasingly at odds with aetiological research, which increasingly suggests that mental disorders are rather gradual deviations from typical brain functions.

This, in turn, suggests that mental disorders should be classified as points or areas on spectra rather than the neat categories propounded by the DSM. One effort at building such a nosology was begun by the NIMH in 2010.

The project dubbed the RDoC, is still confined to research, and is not ready for clinical application.

The myriad problems in psychiatric research and practice preclude any consensus on the accuracy of psychiatric diagnoses and are likely to do so until they are resolved.

The field has not converged on a corrective program, though there exist a number of such programs competing for widespread support.

What did the Rosenhan study suggest in 1973?

The Rosenhan study in 1973 suggested that psychiatric diagnoses are often subjective and unreliable. Rosenhan and his associates feigned hallucinations to get admitted to mental hospitals but acted normally afterward.

Despite this, they were held for significant periods and treated as if they were genuinely mentally ill. The study highlighted issues with the validity of psychiatric diagnosis and the stigma attached to mental illness.

What did the classic study by Rosenhan reveal about the power of labels that are applied to individuals?

The classic study by Rosenhan showed the influential effect of labels on individuals, specifically psychiatric labels. By pretending to have hallucinations, mentally healthy participants gained admission to psychiatric hospitals.

The study demonstrated that once labeled as mentally ill, their behaviors were consistently interpreted in that context, even when they stopped simulating symptoms.

Adam, D. (2013). On the spectrum. Nature, 496(7446), 416.

Insel, T. .R. (2013, 29th April). Transforming Diagnosis. [Weblog]. Retrieved 4 November 2020, from https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

Kapur, S., Phillips, A. G., & Insel, T. R. (2012). Why has it taken so long for biological psychiatry to develop clinical tests and what to do about it?. Molecular psychiatry, 17 (12), 1174-1179.

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

Sharp, C., Fowler, J. C., Salas, R., Nielsen, D., Allen, J., Oldham, J., Kosten, T., Mathew, S., Madan, A., Frueh, B. C., & Fonagy, P. (2016). Operationalizing NIMH Research Domain Criteria (RDoC) in naturalistic clinical settings. Bulletin of the Menninger Clinic, 80 (3), 187–212.

Further Information

• Rosenhan, D. L. (1973). On being sane in insane places. Science, 179(4070), 250-258.
• Spitzer, R. L. (1975). On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan”s” On being sane in insane places.”
• David Rosenhan’s Pseudo-Patient Study

The Rosenhan Experiment That Shattered the Boundaries of Sanity

• Post author: Becky Storey
• Post published: December 4, 2019
• Reading time: 7 mins read
• Post category: Human Brain / Psychology & Mental Health / Uncommon Science

In 1973, David Rosenhan published a psychological paper titled “On Being Sane in Insane Places” . This study became known famously as the Rosenhan Experiment . He wanted to discover whether medical professionals could really tell the difference between the sane and the insane.

His research sent shockwaves through the psychiatry community and ultimately changed how diagnoses are given. Despite the praise though, there have been several conflicting ideas and criticisms of his work too.

The Rosenhan Experiment

The Rosenhan Experiment used eight willing participants, including Rosenhan himself. Some were psychologists too, while others hadn’t had anything to do with the profession at all. They were all mentally healthy. He called these participants “pseudopatients” .

They gave fake names and occupations, but kept all other details about themselves truthful, such as their family situations and childhoods. Their goal was to be admitted into a psychiatric unit based on the fictional symptoms they reported.

They each contacted hospitals across five US states and reported the same symptoms. They said they were hearing voices that said things like “hollow”, “empty” and “thud” . Rosenhan chose these words because they suggest an existential crisis , in the form of psychosis.

At the time, there was no literature on existential psychosis. As per the goal for the Rosenhan Experiment, the intention was to learn whether doctors would diagnose something based on symptoms that weren’t recognized as part of any psychiatric disorder .

All eight pseudopatients were successful in getting admitted. They were all diagnosed with Schizophrenia , based on the one symptom they reported, except for one who was given the diagnosis of Bipolar Disorder . Once they were let into the hospitals, they all stopped exhibiting their fake symptoms and returned to being entirely themselves. The experiment into how firmly the doctors would stick to their diagnosis had finally begun.

After Admittance

Once a pseudopatient entered the hospital, they began testing the doctors and nurses and recording their results for Rosenhan’s Experiment. They engaged in typical day to day activities on the ward, such as socializing, playing games and speaking to staff and other patients as they would in the outside world.

When asked how they felt, Rosenhan instructed them to say that they are well and to make it clear that they no longer experience any abnormal symptoms. Despite, their normal behavior, no doctor ever considered that their diagnosis was incorrect.

In 4 of the 12 hospitals tested in the Rosenhan Experiment, the pseudopatients also observed the staff’s interactions with the patients. They reported that very few ever paid much attention to those who needed it. Most of them wouldn’t respond to questions such as “when am I likely to be discharged?”, despite the calm and sane nature of the question.

This ultimately became a common criticism of the Rosenhan Experiment. Maybe it wasn’t a misunderstanding of sanity, but simply not giving enough time to finding out.

All of the pseudopatients hated their time on the wards. They described becoming depersonalized and feeling powerless . They all wanted to leave immediately. Their stays ranged between 7 and 52 days before discharge, and they were all discharged under the notion that their psychosis was “in remission”. At no point was it considered by the staff that they might not have a psychiatric disorder at all.

The staff were often absent and rarely spent time with the patients. They kept their interactions to a minimum. Some pseudopatients even reported the doctors and nurses being abusive and rude.

Rosenhan’s Results

Ultimately, the Rosenhan Experiment resulted in the anticipated way. David Rosenhan concluded that hospitals truly could not distinguish between the sane and the insane .

Some of the records and observations made by the pseudopatients were shocking and further confirmed the point that the Rosenhan Experiment had been set up to prove. Other genuine patients in the hospitals easily picked the pseudopatients out as fakes.

35 of the 118 real patients they interacted with noticed that they didn’t belong there. One real patient even accused a pseudopatient of being a journalist. This leads us to wonder if the pseudopatients were clearly fakes , the doctors were just not attentive enough to notice.

Some of the doctors and nurses even went as far as to label normal or healthy behaviors as pathological . In three nurses’ reports relating to the pseudopatients, they refer to their writing in notebooks as a psychotic behavior. This writing was done for the purposes of the Rosenhan Experiment and is a “sane” thing to do for any person who struggles with their mental health.

Similarly, it was reported that a group of staff had accused patients who gathered early for dinner of having Oral-Acquisitive Syndrome. In reality, as the pseudopatients reported, they were simply bored.

Rosenhan even conducted a second experiment where the doctors and nurses were aware that there was a pseudopatient on the ward. 83 out of a possible 193 patients were identified as suspicious by at least one member of staff. Rosenhan then revealed that there was no pseudopatient at all. Clearly, there was no uniform idea of what they were looking for in a “sane” person.

Criticisms of the Rosenhan Experiment

Unfortunately, despite its general success, some psychologists have presented issues with the Rosenhan Experiment . Some raise issues with the confidentiality of the experiment. While Rosenhan may have had good intentions, he kept the names of the hospitals and the pseudopatients confidential. This meant verifying his findings was impossible.

Rosenhan’s experiment also reports conflicting views on the doctors and nurses who tended to the pseudopatients. While in some reports they’re considered ignorant and abusive, in others they’re praised for being intelligent and committed.

Critics also wonder if the pseudopatients behaved “normally” at all. By writing and observing and the fear of being caught, there’s a chance the Rosenhan Experiment was flawed from conception .

Ultimately, both Rosenhan and his critics came to the same conclusion. It is difficult to distinguish the sane from the insane, even for medical professionals. As part of the human experience, we swing through all sorts of emotions all the time. Sadness, anxiousness, and anger are all normal feelings.

Sane and insane are extreme labels and we all sit on a spectrum rather than within definite labels. Fortunately, this is how modern-day psychiatrists view mental health now – in part due to the success of the Rosenhan Experiment.

References :

• https://science.sciencemag.org
• http://cyberlaw.stanford.edu

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This Post Has One Comment

A few similar studies should be done with GPs. I have had several incidences with doctors. Some would give me any script I wanted. Some pushed scripts on me. Some refused to believe that I had a health issue that scripts cant resolve. When i seen another doctor, I found out it was worse because I waited (due to the other doctor) I was given a proper remedy. And lastly but most important, how many times I have asked a doctor “why” is this happening? One of two responses “it could be many things” or a bewildered look on their face as they try to compose themself to answer.

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REPLICATING ROSENHAN’S STUDY: A METHODOLOGICAL AND ETHICAL ARGUMENT AND PROPOSAL

• Posted by Alan Eppel
• Posted in Ethics

Normal 0 false false false EN-CA X-NONE X-NONE

The Rosenhan Experiment: When Fake Mental Patients Fooled Psychiatrists

How the rosenhan experiment showed that "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.".

Duane Howell/The Denver Post via Getty Images Dr. David Rosenhan. 1973.

What does it mean to be sane? How reliably can even medical professionals distinguish the sane from the insane?

Psychologist Dr. David Rosenhan of Stanford University had long been interested in these age-old questions and, in 1969, devised a unique experiment to put them to the test.

Rosenhan and seven other perfectly sane subjects went undercover inside various psychiatric hospitals from 1969-1972 and acted insane in order to see if the doctors there could tell that they were faking. The doctors could not.

How The Rosenhan Experiment Was Carried Out

Wikimedia Commons St. Elizabeths Hospital in Washington, D.C., one of the locations used in the Rosenhan experiment.

The Rosenhan experiment’s eight sane subjects went inside 12 different psychiatric hospitals, all but one state- or federally-run, spread across five U.S. states. These pseudopatients consisted of three women and five men, including Rosenhan himself, whose occupations ranged from actual psychologist to painter.

The participants assumed false names and professions and were instructed to set up appointments at the hospitals and claim that they had been hearing strange voices muttering words like “empty” and “hollow” (these words were meant to evoke an existential crisis, as in, “my life is empty and hollow”). On the basis of these appointments, every single pseudopatient was admitted to the hospital that they contacted.

According to the landmark 1973 report that Rosenhan published about his experiment, On Being Sane in Insane Places , “none of the pseudopatients really believed that they would be admitted so easily.”

Not only was every pseudopatient admitted, but all except one received a diagnosis of schizophrenia (the other diagnosis was “manic-depressive psychosis”). All they had done was feign auditory hallucinations. They exhibited no other symptoms and invented no false details about their lives aside from their names and professions. Yet they were diagnosed with serious psychological disorders.

Once checked into the hospitals and diagnosed, the pseudopatients were on their own. None knew when the doctors would deem them fit for release — or find out that they were faking first.

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The Disturbing Results

U.S. National Library of Medicine A patient (not involved with the Rosenhan experiment) at St. Elizabeths Hospital. Circa 1950s.

At the start of the experiment, the patients’ biggest concern was that they would “be immediately exposed as frauds and greatly embarrassed,” according to Rosenhan. But as it turned out, there was no need to worry on this account.

There was a “uniform failure to recognize sanity” in any of the pseudopatients, Rosenhan wrote, and not one of them was ever found out by the hospital staff. The pseudopatients showed no new symptoms and even reported that the strange voices had gone away, yet the doctors and staff continued to believe that their diagnoses were correct.

In fact, hospital staff would observe totally normal behavior on the part of the pseudopatients and characterize it as abnormal. For instance, Rosenhan instructed the pseudopatients to take notes on their experiences. And one nurse who observed this note-taking wrote in a daily report that the “patient engages in writing behavior.”

As Rosenhan saw it, doctors and staff would assume that their diagnosis was correct and work backward from there, reframing everything they observed so that it would be in harmony with that diagnosis:

“Given that the patient is in the hospital, he must be psychologically disturbed. And given that he is a disturbed, continuous writing must be a behavioral manifestation of that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia.”

Likewise, one of the pseudopatients was a man who described his home life by truthfully reporting that he had a warm relationship with his wife, with whom he fought occasionally, and children, who he spanked minimally for misbehavior. But because he was admitted to a psychiatric hospital and diagnosed with schizophrenia, his discharge report stated that “His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings.”

Had the man not been a patient in a psychiatric hospital, his common, mundane home life surely wouldn’t have been described in such dark tones.

“Diagnoses were in no way affected by the relative health of the circumstances of a pseudopatient’s life,” Rosenhan wrote. “Rather, the reverse occurred: The perception of his circumstances was shaped entirely by the diagnosis.”

Library of Congress/Wikimedia Commons A patient sits inside St. Elizabeths Hospital. 1917.

And in addition to stubbornly sticking to their diagnoses, hospital staff would treat the pseudopatients coldly. Interactions with the staff ranged from disinterested at best to abusive at worst. Even when the pseudopatients attempted to engage with staff in a friendly, conversational manner, responses were perfunctory (when given at all).

But while hospital staff treated the pseudopatients poorly and never realized they were faking, the actual patients often had no trouble detecting them. When the researchers were able to keep track, 35 out of 118 actual patients blatantly accused the pseudopatients of faking, with some outright stating, “You’re not crazy. You’re a journalist or a professor.”

Nevertheless, the doctors never got wise. The pseudopatients were eventually released — stays ranged from 7 to 52 days, with an average of 19 — but all with the same diagnosis under which they’d been admitted. They were released, however, because doctors decided that their condition was “in remission.”

As Rosenhan wrote:

“At no time during any hospitalization had any question been raised about any pseudopatient’s simulation. Nor are there any indications in the hospital records that the pseudopatient’s status was suspect. Rather the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be ‘in remission’; but he was not sane, nor, in the institution’s view, had he ever been sane.”

The Legacy Of The Rosenhan Experiment

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals,” Rosenhan wrote at the outset of his report’s conclusion.

Rosenhan theorized that the willingness of the hospitals to admit sane people resulted from what’s known as a “Type 2” or “false positive” error, which results in a greater willingness to diagnose a healthy person as sick than a sick person as healthy. This kind of thinking is understandable to a point: failing to diagnose a sick person usually has more severe consequences than misdiagnosing a healthy one. However, the consequences of the latter can be dire.

Either way, the results of the Rosenhan experiment caused a sensation. People were astonished about the unreliability of psychiatric diagnoses and the ease with which hospital staff had been duped.

However, some researchers criticized the Rosenhan experiment, stating that the pseudopatients’ dishonest reporting of their symptoms made the experiment invalid because patients’ self-reports are one of the cornerstones on which psychiatric diagnoses are built.

But other researchers have affirmed Rosenhan’s methods and results, with some even partially replicating his experiment and coming up with similar conclusions .

Of course, even Rosenhan was not the first American to bring the darker side of the mental health system to light in this way.

Wikimedia Commons Nellie Bly

In 1887, journalist Nellie Bly went undercover in an insane asylum and published her findings as Ten Days in a Mad-House .

Bly too concluded that many of the other patients were just as “sane” as she and had been sent to the asylum unfairly. Bly’s work resulted in a grand jury investigation that attempted to make psychiatric examinations more thorough in an attempt to make sure that less “sane” people were institutionalized.

Almost a century later, Rosenhan showed that the mental health profession still had a long way to go in being able to reliably and consistently distinguish the sane from the insane.

After the results of the Rosenhan experiment were published, the American Psychiatric Association changed the Diagnostic and Statistical Manual of Mental Disorders . The new version of the manual, published in 1980, presented a more thorough list of symptoms for every mental illness and stated that, in order to diagnose a patient with a certain disorder, multiple symptoms had to be present as opposed to just one.

These changes in the manual survive to this day, although it has yet to be conclusively determined whether it has been successful in preventing false diagnoses. Perhaps the Rosenhan experiment could be duplicated today.

New Research Casts Doubt

Because the pseudopatients of the Rosenhan experiment would never be able to talk about their participation and because relatively little had been written authoritatively about the course of the study itself, it became a difficult experiment to discuss and critique — there simply wasn’t much to argue with. However, subsequent research that utilized uncovered documentation from the original experiment eventually found fault with Rosenhan’s study.

In her 2019 book on the Rosenhan experiment, The Great Pretender , journalist Susannah Cahalan cited unearthed primary sources like correspondence, diary entries, and excerpts from Rosenhan’s unfinished book. And such documentation, Cahalan found, actually contradicted the results that Rosenhan published on certain points.

For one, Cahalan claimed that Rosenhan himself, when undercover in an institution as part of his own experiment, told doctors there that his symptoms were quite severe, which would explain why he was so quickly diagnosed. This is significant because it runs counter to Rosenhan’s report, which claimed that he told doctors of some relatively light symptoms, which is precisely what made those doctors’ diagnoses seem like such an overreaction.

Furthermore, when Cahalan was finally able to track down one of the pseudopatients, he summed up his experience inside an institution with one word — “positive” — a stark rebuttal of the horror shows that Rosenhan’s participants had supposedly endured. But Rosenhan allegedly ignored this data when drafting his report.

“Rosenhan was interested in diagnosis, and that’s fine, but you’ve got to respect and accept the data, even if the data are not supportive of your preconceptions,” said the participant in question, Harry Lando.

If such claims are accurate and the Rosenhan experiment didn’t quite prove what it purported to, who knows how the course of psychiatric care in the U.S. may have unfolded in the decades since.

After this look at the Rosenhan experiment, read up on the infamous Milgram experiment and Stanford prison experiment . Then, take a disturbing look inside mental asylums of decades past .

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Key study: “On being sane in insane place” (Rosenhan, 1973)

Travis Dixon April 2, 2019 Abnormal Psychology , Qualitative Research Methods

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Rosenhan’s famous study attempted to demonstrate the unreliable nature of psychiatric diagnosis in the 1970s and how poorly patients were treated in psychiatric hospitals. While his methods were a little suspect, the study seemed to make the point Rosenhan was hoping for. 

Background Information

One of the most influential studies conducted investigating the difficulties in defining normality and abnormality, and the inherent repercussions for valid and reliable diagnoses of psychological disorders, was conducted by David Rosenhan. This research was published in 1973, a time when psychiatric hospitals were quite different to the way they are today.

Prior to this study, some researchers had conducted participant observations of psychiatric hospitals, but this was often for a short time and the hospital staff knew of their presence. Rosenhan wanted to take this research one step further and so he conducted a participant, naturalistic, covert observation. He was interested in investigating whether the 8 pseudopatients(people pretending to be patients)  would be diagnosed based on their objective symptoms and behaviours, or if the nature of the environment would influence the interpretation of their behaviours by the professionals who were diagnosing them. Perhaps his aim can be best summarised by the question he poses in the opening to his article:

Psychiatric hospitals were once called “insane asylums,” “mental hospitals,” or more informally “nut houses” or “loony bins.” The classic image of an “insane” person is them wearing a straightjacket.

“If sanity and insanity exist, how shall we know them?”

Methodology and Results

Rosenhan was one of the pseudopatients, along with 7 others. They were an eclectic mix of people who used false names and occupations. There was a graduate student of psychology, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife.

They sought admission into 12 different hospitals on the East and West coasts of the United States. The only symptom they were told to give the hospitals was that they had been hearing voices from a stranger’s voice that was the same gender as them, and the voices were unclear but they thought they said “thud”, “empty” and “hollow”. One reason why these words were chosen was because there is a suggestion that they are signaling some sort of crisis in the individual’s life, such as their life “is empty and hollow”. Once they were granted admission into the hospital, all the other details about their lives and their personal histories that they told the hospital staff were true.

Of the 12 admissions to the hospitals, 11 were diagnosed with schizophrenia and one was diagnosed with manic-depressive psychosis. They remained in the hospitals for a range of 7 to 52 days, with an average of 19 days.

Schizophrenia is a mental disorder that has many varieties. It is mainly characterized by an inability to understand reality (e.g. not being able to determine what is real and what is not).

Once the pseudopatients were admitted to the hospital, they carried on behaving normally and told the staff their symptoms had stopped. They took notes and made other observations, at first hiding this in case the staff found out, but after they realized the staff weren’t paying attention to them, they took notes freely. This resulted in other patients in the hospital raising questions about the authenticity of the pseudopatients’ illnesses. In fact, during the first 3 admissions to hospitals, 35 of 118 patients expressed some concern regarding whether or not the pseudopatients were really ill. This raises an interesting question, like why can the diagnosed “mentally insane” recognize sanity, while the trained professionals cannot?

Follow-up study

After this original study was conducted, one hospital heard of the findings and challenged Rosenhan to send pseudopatients to their hospital with the belief that they would be able to spot the fakes from the genuine patients. Over a three month period, 193 patients were admitted for treatment and received a judgement based on the staffs’ beliefs if they were an actual patient or not. Of these 193, 41 were judged with high confidence by at last one member of the staff to be a pseudopatient, while 19 were suspected as being a pseudopatient by a psychiatrist and at least one other member of the staff. In fact, Rosenhan had not sent any pseudopatients during this time.

Conclusions

While they were on the hospital wards, the pseudopatients made notes about their experiences and in his article Rosenhan details the dehumanization that was experienced by the pseudopatients while they were in the care of the hospital staff. He believes that it is the power of the label (in this case schizophrenia) that influences the way the clinicians interpret their behaviour: “Once a person is diagnosed abnormal, all of his other behaviours are colored by that label”. For example, a perfectly normal description of one of the pseudopatient’s relationships with family members was interpreted by the clinician in a way that was consistent with his diagnosis of schizophrenia. Rosenhan’s study highlights ethical considerations regarding diagnosis, primarily those concerned with the power of labels and stigmatisation.

Critical thinking considerations

• How does this study demonstrate difficulties in defining normality and abnormality?
• How does this study demonstrate validity and reliability issues related to the diagnosis of psychological disorders?
• How does this study demonstrate ethical considerations in diagnosis, such as the effects of labels and the potential for stigmatisation?
• Are there limitations to this study? For example, why might we be limited in applying these findings to today’s psychiatric hospitals?

Interview with David Rosenhan…

Rosenhan, David L. “On Being Sane in Insane Places,” Science , Vol. 179 (Jan. 1973), 250-8. (Accessed from isites.harvard.edu). (Full “On Being Sane in Insane Places” article  here )

Ararat Lynatic Asylym – psychiatric hospitals were a lot less welcoming and pleasant in the past than they are today. (Image from wikipedia)

Psychiatric Hospitals

The following are some short clips to develop your schematic understanding of what psychiatric hospitals for mentally ill people used to be like. I also highly recommend reading and/or watching “One Flew Over the Cuckoo’s Nest” if you’re interested in this topic.

Clips from the film “Patch Adams” with the late and great Robin Williams…

Therapy Session:

Interview (this scene does a great job of highlighting the detachment and apathy from the Doctors.

Squirrels: A touching scene with two patients.

Patch Adams decides he wants to become a Doctor because he wants to help people….

One Flew Over the Cuckoo’s Nest

Travis Dixon is an IB Psychology teacher, author, workshop leader, examiner and IA moderator.

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““On Being Sane in Insane Places” … it is a work half done.”

Atul agarwal.

Retired Professor and Consultant

“ON BEING SANE IN INSANE PLACES” TURNS FIFTY

Rosenhan through a “scientific experiment aimed at exposing the system’s travesties”.[ 1 ] His article[ 2 ] naturally had an ominous title. Quite a stir was created on its publication, as multiple normal people or pseudopatients could get admitted to various psychiatric hospitals under the diagnostic labels of serious illnesses. In this brief communication, I will try to explore the origins of the article, the reception that the article had during the early years after its publication and subsequently during the twenty-first century, Rosenhan’s response to his critics, and the article’s contemporary relevance.

The students, of Rosenhan’s 1969 abnormal psychology class, complained that his course was too conceptual and abstract. Rosenhan responded by asking them to check into a local psychiatric hospital to personally know the mentally ill. But as he cautiously checked things out for himself first and emerged humbled from nine traumatizing days in a locked ward, he had to abandon the idea of putting students through that experience. But an experiment was born.[ 1 ]

Early years after the article

One of the major concerns of the deeply embarrassing 1973 article was the unreliability of the psychiatric diagnoses. The same year saw homosexuality most humiliatingly struck as an abnormality from the DSM. The 1960s and early 1970s were bad for American psychiatry, which was being hit by multiple crises, including the anti-psychiatry movement.[ 3 ]

Robert Spitzer in 1974 became a natural choice for chairing the task force of DSM-III, because of his involvement in developing Research Diagnostic Criteria … and resolving the gay controversy. “Gay Psychiatric Association [a secret group] invited Spitzer to sit in on a meeting … If such successful people—without any obvious distress or impairment—could be gay, then how could they call it a disorder?”[ 4 ]

Soon influential voices in American psychiatry were seen mounting a collective defense of the profession.[ 3 ] So, after Spitzer became the chair, he naturally spearheaded an attack on Rosenhan[ 5 - 9 ]… while expressly admitting[ 7 ] the weaknesses of psychiatric diagnoses. “So be it.” Spitzer wrote, “But where did Rosenhan get the idea that psychiatry is the only medical specialty that is plagued by inaccurate diagnosis?” Then he attacked Rosenhan by devoting a long paragraph and quoting studies to prove that internal medicine too was plagued by the inaccuracies of diagnoses. Spitzer was personally targeting Rosenhan is clear from the title, abstract, and the entire text,[ 7 ] which begins: “Some foods taste delicious but leave a bad aftertaste. So it is with Rosenhan’s study, “On Being Sane in Insane Places”“.

In his defense, Rosenhan argued[ 10 ]: “The issue is not that the pseudopatients lied or that the psychiatrists believed them … [or] whether the pseudopatients should have been admitted … The issue is the diagnostic leap that was made between a single presenting symptom, hallucination, and the diagnosis, schizophrenia (or, in one case, manic-depressive psychosis). That is the heart of the matter.”

Coming back to Wilson,[ 3 ] who wrote quoting Robert Spitzer (personal interview, May 24, 1989): “at APA annual meetings in the 1960s, the academic psychiatrists interested in presenting their work on descriptive diagnosis would be scheduled for the final day in the late afternoon. No one would attend. Psychiatrists simply were not interested in the issue of diagnosis.”

Spitzer[ 7 ] did not even try to defend the condition of the inpatients: “I shall not dwell on the latter part of Rosenhan’s study, which deals with the experience of psychiatric hospitalization. … I find it hard to believe that conditions were quite as bad as depicted, but they may well be.”

Rosenhan revisited during the twenty-first century

Slater covered Rosenhan’s Experiment in her 2004 popular nonfiction.[ 11 ] Even that nonacademic writing evoked a well-planned and sharp academic response from Spitzer, including a formal study to contradict “Slater’s findings”… and it was another opportunity to attack Rosenhan. “The [Rosenhan’s 1973] study was like a sword plunged into the heart of psychiatry. … The study was widely acclaimed in the popular news media, and two editorials in The Journal of the American Medical Association endorsed its findings … Many introductory psychology textbooks cited the study … Rosenhan’s study had a significant impact on the psychiatric and psychological literature: a Web of Science search conducted by the authors revealed that Rosenhan’s study has been cited over 750 times since its publication. In contrast, the critiques of Rosenhan’s study have received far less attention”.[ 12 ]

In November 2022, Google Scholar returned 4502 citations for Rosenhan,[ 2 ] while its critique[ 7 ] returned only 211. More importantly “flaws in Rosenhan’s study … [was not a proof that psychiatry] had an adequately reliable diagnostic system”.[ 13 ] While writing the 2007 Foreword Spitzer admitted that the book The Loss of Sadness [ 13 ] “caused me to rethink my own position [about DSM approach]” and he hoped that the issue would become “one of the major topics that should be considered in the upcoming revisions that will yield the DSM-V ” (pp. vii-x).

While working on DSM-III drafts, Spitzer “often returned to Rosenhan’s study and asked himself: Would David Rosenhan and his pseudopatients get past this one?… Without Rosenhan’s study, Frances told me, “Spitzer could never have done what he did with the DSM-III”“.[ 4 ] Unlike his wife and Frances … Spitzer never publicly admitted that Rosenhan influenced his creation.

In an obituary, Ross, and Kavanagh[ 14 ] noted: “Some critics saw this [Rosenhan] study as a personal attack on psychiatry and clinical psychology, even though the article’s emphasis was on diagnostic practices and contextual influences.” They quoted portions of the article’s concluding paragraph, which emphasized Rosenhan’s empathy and humanity towards the hospital staff. The whole paragraph is: “Quite the contrary, our overwhelming impression of them was of people who really cared, who were committed and who were uncommonly intelligent. Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves than to personal callousness. Their perceptions and behavior were controlled by the situation, rather than being motivated by a malicious disposition”.[ 10 ]

Lee Shulman eulogized that Rosenhan’s work constituted “more than the report of an immensely inventive piece of research … it is a proclamation, a moral outcry, a scream of pain and a demand that the world bear witness to the consequences of wrongful diagnosis, of ungrounded labeling, of institutions whose very design shapes errors of diagnosis”.[ 14 ]

Cahalan[ 4 ] wrote: “Rosenhan’s flawed work had an effect on Robert Spitzer and the creation of the DSM … [and] that the study had a wide influence, contributing to the shuttering of psychiatric hospitals. … Rosenhan’s paper, as exaggerated, and even dishonest, as it was, touched on truth as it danced around it … The messages were worthy; unfortunately, the messenger was not.” While commenting on the book, Pols in Science wrote: “with The Great Pretender, yet another well-known and rhetorically powerful experiment in psychology bites the dust”.[ 15 ] But Abbott was less forthright in condemning Rosenhan, because “she [Cahalan] cannot be completely certain that Rosenhan cheated. But she is confident enough to call her engrossing, dismaying book The Great Pretender”.[ 1 ]

“In my first reading of “On Being Sane in Insane Places”… the first of hundreds of readings to come, I saw immediately why so much of the general public had hailed it—and why psychiatry writ large despised it. … I pinpointed so much of my own disappointment and frustration as a former patient myself. And I could feel, viscerally, the undercurrent of rage that travels through his paper that I feel, too, when I picture the face of my mirror image, that anonymous young woman, trapped in a psychiatric diagnosis, who would never be the same”.[ 4 ] And Dr. Deborah Levy called Cahalan “a modern-day pseudopatient”. So Cahalan never disagreed with Rosenhan’s observations. She did not seem to be promoting any vested interests, and she was never absolutely sure that Rosenhan faked.

The contemporary relevance: Psychiatry will remain a work half done till we discover a better paradigm

““On Being Sane in Insane Places” is a negative work,” Rosenhan responded to his adversaries. “It tells what is wrong with treatment and diagnosis, without telling how it might be improved. … It tells those who have labored to improve psychiatric care that their efforts are grossly insufficient, without offering alternatives of demonstrated value. … It leaves scientists and practitioners in the lurch, urging them to abandon the little they have by way of hospital treatment and diagnosis, without providing them alternative tools. It would destroy a paradigm without providing an alternative. In short, it is work half done [emphasis added]”.[ 10 ]

Even today, we continue to destroy the paradigm without realizing that we are acting like Rosenhan. The Lancet in the years 2007 and 2011 published two series about mental health. These twelve articles, whose references are here,[ 16 ] paint a grim narrative of the mental health scenario, especially in low and middle-income countries of Asia, Africa, and Latin America. The ground reality is even grimmer in India.[ 17 ]

We must recall Erwadi where a dargah claims healing powers for the mentally ill … unfortunate conditions prevailed in the asylums.[ 18 ]… and in 2001 roasted alive were twenty-eight mentally challenged. The official response of the Indian psychiatrists to the tragedy was brisk and predictable.[ 19 , 20 ] Siddiqui[ 21 ] is probably showing her wild desperation (and nothing else) when hailing dargahs and other forms of faith healing as forms of critical alternatives to (a less than adequate) psychiatry.

These critiques should reinforce Rosenhan, reminding us of the work that fifty years ago Rosenhan tried to push forward, and that continues to remain half done. It will remain half-done till we find a new and better paradigm. So, it should jolt us to search for a new paradigm. His article[ 2 ] should be seen as an attempt to reform psychiatry in its entirety and not its diagnostic processes alone.

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On being sane in insane places: david rosenhan and his thud experiment.

The “ Rosenhan Experiment”  or Thud experiment was a study conducted to determine the validity of the psychiatric diagnosis. The participants feigned hallucinations to enter psychiatric hospitals but acted usually afterward. They diagnosed them with psychiatric disorders and gave them antipsychotic medication. David Rosenhan, a Stanford University professor, conducted this study, and published it in the journal Science in 1973 under the title “On Being Sane in Insane Places”.

Some consider it an essential criticism of psychiatric diagnosis and broach wrongful involuntary commitment. Rosenhan did the study in eight parts. The first part involved using healthy associates or “pseudopatients” (three women and five men, including Rosenhan himself) who briefly feigned auditory hallucinations to gain admission to twelve psychiatric hospitals in five states in the United States. They admitted all and were diagnosed with psychiatric disorders. After admission, the pseudopatients acted usually and told staff that they no longer experienced any other hallucinations. As a condition of their release, they forced all the patients to admit to having a mental illness and had to agree to take antipsychotic medication. The average time that the patients spent in the hospital were 19 days. They diagnosed all but one with schizophrenia “in remission” before their release. The second part of his study involved a hospital administration challenging Rosenhan to send pseudopatients to its facility, whose staff asserted that they could detect them.

Rosenhan agreed, and they found in the following weeks forty-one out of 193 new patients as potential pseudopatients, with 19 of these receiving suspicion from at least one psychiatrist and one other staff member. Rosenhan sent no pseudopatients to the hospital. While listening to a lecture by R. D. Laing, associated with the anti-psychiatry movement, Rosenhan conceived the experiment to test the reliability of psychiatric diagnoses. The study concluded that “we cannot distinguish the sane from the insane in psychiatric hospitals” and illustrated the dangers of dehumanization and labelling in psychiatric institutions. It suggested that using community mental health facilities that concentrated on specific problems and behaviours rather than psychiatric labels might be a solution. It recommended education to make psychiatric workers more aware of the social psychology of their facilities.

The procedure

Results of the Study

They diagnosed all but one pseudopatient with schizophrenia (the other with the bipolar depressive disorder). They admitted all of them to the hospital and discharged each with a diagnosis of schizophrenia in remission. (i.e. Symptoms were not present at the time of release) the length of hospitalization varied from 7 to 52 days, with an average of 19 days. They never detected pseudopatients, no records or behavior by hospital staff showed that there were any doubts over the authenticity of the patients’ visitors and other patients recognized that some pseudopatients were sane. During the first three hospitalizations, 35 out of 118 patients on the admissions wards voiced their suspicions, such as you are not crazy. You are a journalist or a professor. 

Conclusions

Failure to detect sanity may be because doctors are more likely to favour a type 2 error (they are more likely to diagnose a healthy person as sick) than a type 1 error (than a sick person as healthy) less dangerous this works for medicine but is not necessarily the case for psychiatry as once we label a person as being mentally ill, it is challenging to shift the label the fact that some patients noticed the pseudopatients were sane when the staff did not raise important questions perhaps the results seem to suggest that diagnosis is reliable as they gave all but one individual a diagnosis of schizophrenia when presenting similar symptoms discharge of schizophrenia in remission when they were not actually suffering from any known disorder (affects reliability)it is interesting to note that the staff interpreted many of the pseudo-patients behaviours as being in line with the symptoms of the condition they had diagnosed them with. Rosenman believed that once given a label, we overlook all normal behaviours. For example, they saw their notetaking as an aspect of their pathological behaviour. Staff wrote in one patient’s notes: the patient engages in writing behaviour.

Second Experiment

Another hospital had heard of the findings of the first part of the study, and the staff over there did not believe the results would have occurred in their hospital. Rosenhan informed the staff that in the next three months, one or more pseudopatients would try again to gain entry to the hospital each member of staff was asked to rate every patient (either at admission or on the ward) who wanted admission on a scale from 1 to 10 in terms of whether they thought the patient was a real or fake score of 1 reflected an elevated level of confidence that the patient was fake. Over the 3 months, 193 patients tried to gain admission.

• What was the aim of Rosenhan?
• He wanted to test the reliability of a mental health diagnosis, to see if medical professionals could tell the sane from insane. 
• Was Rosenhan’s experiment or the Thud experiment an experiment?

No, it was an observational study. 

Who were the participants of the thud experiment?

The participants were staff and patients at the twelve hospitals.

Where were the hospitals of Rosenhan’s experiment?

In five states on the East and West coasts of the US. 

Who knew about the pseudopatients in the Thud experiment?

The hospital administrator and chief psychologist

How many pseudopatients were they, and who were they?

8 (3 women and five men) confederates.

Was Rosenhan a pseudo-patient?

Yes, Rosenhan also volunteered as a pseudopatient.

How would patients leave the hospital?

They had to convince the staff they were sane.

What did patients act like when they were admitted them?

They behaved like normal individuals. 

What did the staff do once in the wards?

Took notes. 

Were notes taken in the open?

Only once they were sure staff were not suspicious

What words they chose as the voices?

Thud, empty, and hollow.

What did they change about the patient’s information?

Just the name and occupation, all personal backgrounds stayed the same

How did patients contact the hospital?

Called them up.

What did patients report?

Hearing voices

What did Rosenhan measure?

How many days it took for the psychiatrists to release the patients.

Did they give the patients drugs?

Yes, but they did not swallow the medications. 

What were the patients diagnosed with?

11 schizophrenia and 1 manic depressive disorder

What did the average days of stay in the hospital?

Who many days did it vary by?

Were patients detected?

No, no evidence or records that staff doubted the authenticity

How many of the patients on the ward voiced their concerns?

What did real-life patients say?

‘You’re not crazy, you’re a journalist. 

How many were admitted to hospitals?

What is a type 2 error?

Diagnose a healthy person as sick

What is a type 1 error?

Diagnosing a sick person as healthy

What error did the doctors make?

Why did they make this type of error?

Considered less dangerous?

What is the problem with a type 2 error in mental health?

Hard to move the stigma

Why was it thought that even when behaving normally they were not let out?

Once given a label, they overlook all normal behavior.

Is reliability good?

Could be said to be as all same diagnosis but did not have it

What was the aim of his second study?

To investigate if we could reverse the tendency to diagnose sane as insane.

Why did a second experiment take place?

They said that the results in the first one would not happen in theirs.

What did Rosenhan inform the hospital in experiment two?

That he would send one or more pseudopatients in over the course of three months

What were the staff asked to do in experiment-two?

Rate patients on a scale of 1-10 of how real they were (1 being fake)

How many patients tried to gain admission during experiment two?

How many patients did Rosenhan send in for the second experiment?

How many patients did they judge as fake in the second experiment?

How many did one psychiatrist suspect in the experiment two?

Twenty-three

What is the conclusion?

The results show issues with the reliability and validity of diagnosis and strongly suggest that it is not possible to detect the sane from the insane, as staff members could not identify that none of the patients were pseudopatients

What do the results show?

Issues with reliability and validity

When did the study take place?

•   Gaughwin, Peter (2011). “On Being Insane in Medico-Legal Places: The Importance of Taking a Complete History in Forensic Mental Health Assessment”. Psychiatry, Psychology, and Law. 12(1): 298–310. doi:10.1375/pplt.12.2.298. S2CID 53771539.
• Rosenhan, David (19 January 1973). “On being sane in insane places”. Science. 179 (4070): 250–258. Bibcode:1973Sci...179..250R. doi:10.1126/science.179.4070.250. PMID 4683124. S2CID 146772269. Archived from the original on 17 November 2004.
• Slater, Lauren (2004). Opening Skinner’s Box: Great Psychological Experiments of the Twentieth Century. W. W. Norton. ISBN 0-393-05095-5.
• Kornblum, William (2011). Mitchell, Erin; Jucha, Robert; Chell, John (eds.). Sociology in a Changing World (Google Books)(9th ed.). Cengage learning. p. 195. ISBN 978-1-111-30157-6.
• Spitzer, Robert (October 1975). “On pseudoscience in science, logic in remission, and psychiatric diagnosis: a critique of Rosenhan’s “On being sane in insane places””. Journal of Abnormal Psychology. 84 (5): 442–52. doi:10.1037/h0077124. PMID 1194504. S2CID 8688334.
• Abbott, Alison (29 October 2019). “On the troubling trail of psychiatry’s pseudopatients stunt”. Nature. 574 (7780): 622–623. Bibcode:2019Natur.574..622A. doi:10.1038/d41586-019-03268-y. “But some people in the department called him a bullshitter,” Kenneth Gergen says. And through her deeply researched study, Cahalan seems inclined to agree with them.
• Temerlin, Maurice (October 1968). “Suggestion effects in psychiatric diagnosis”. The Journal of Nervous and Mental Disease. 147 (4): 349–353.  doi:10.1097/00005053-196810000-00003 . PMID 5683680. S2CID 36672611.
• Loring, Marti; Powell, Brian (March 1988). “Gender, race, and DSM-III: a study of the objectivity of psychiatric diagnostic behavior”. Journal of Health and Social Behavior. 29 (1): 1–22. doi:10.2307/2137177. JSTOR 2137177. PMID 3367027.
• Moran, Mark (7 April 2006). “Writer Ignites Firestorm With Misdiagnosis Claims”. Psychiatric News. American Psychiatric Association. 41 (7): 10–12. doi:10.1176/pn.41.7.0010. ISSN 1559-1255.

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On Being Sane in an Insane Place – The Rosenhan Experiment in the Laboratory of Plautus’ Epidamnus

• Published: 01 October 2013
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Plautus’ Roman comedy Menaechmi ( The Two Menaechmuses ) of c. 200 BC anticipates in fictional form the famous Rosenhan experiment of 1973, a landmark critique of psychiatric diagnosis. An analysis of the scenes of feigned madness and psychiatric examination suggests that the play (and the earlier Greek play from which it was adapted) offers two related ethical reflections, one on the validity of psychiatric diagnoses, the other on the validity of the entire medical model of insanity—that is, of the popular notion and political truth that mental illness is a (bodily) disease “like any other.” This essay is offered as a contribution to the interpretation of the play as well as to the history of psychiatry.

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Burzacchini ( 2007 ) reviews suggestions for Menaechmi ’s model. Posidippus of Cassandreia (316 – c. 250 BC) is often thought to be its author. I return to the question in §7 below.

Readers can watch Rosenhan summarizing it himself at http://www.youtube.com/watch?v=j6bmZ8cVB4o (accessed September 11, 2013).

An earlier charge (198) is colloquial rather than clinical.

At v. 902 Menaechmus in frustration refers to his errand boy as meus Ulixes, suo qui regi tantum concivit mali (“That Ulysses of mine, who caused so much trouble for his king”). The “king” is of course Menaechmus himself (a parasite’s patron is commonly called rex ). What legend is he alluding to? Perhaps to Odysseus’ legendary malingering. On the eve of the Trojan War Odysseus feigned insanity to avoid conscription, but was subsequently detected at the behest of Agamemnon. In the sequel Odysseus murdered Palamedes, whose father in turn convinced Clytemnestra, Agamemnon’s wife, to take Aegisthus as her lover—who, in turn, murdered Agamemnon (Apollodorus Epitome 6.7–9).

According to Stok ( 1996 ), bare arms were medically associated with insomnia in antiquity (p. 2294).

Some editors reassign the lines and understand:

Psychiatrist ( pinching Menaechmus’ arm ) Do you feel anything? Menaechmus Of course I do!

With this much-misunderstood question the doctor is probing two points derived from Hippocratic medical inquiry of the times:

Explicitly he is inquiring about a sudden change in drinking habits . As Rankin ( 1972 ) has noticed, Hippocratic teaching held that a sudden change in dietary habits could produce malign effects on the body (p. 187). At the end of chapter 10 of On Regimen in Acute Diseases Hippocrates states, “White and dark wines ( leukos te kai melas oinos ) are both strong, but if a person makes an unaccustomed ( para to ethos ) switch to one from the other, they will alter many things in his body.” The repetition in Menaechmus’ reply of soleam (= Greek to ethos ), “normally,” indicates that the doctor is inquiring whether Menaechmus customarily drinks “white” (Greek leukos ~ album ) or “dark” wine (Greek melas ~ atrum ) ( HVA part 3 Kühn 15.626–30 = CMG 5.91 Helmreich). Had he gotten a chance to ask it, the doctor’s next question would have been, “Have you been drinking the other kind today?”

Implicitly the doctor is afraid Menaechmus has been drinking dark wine, since according to Ps.-Aristotle ( Problemata 30.1, 954a [cf. 953b]) it produces the same symptoms as does black bile in melancholic individuals.

These observations decisively refute an older suggestion that the doctor’s questions relate to the regularity of Menaechmus’ bowel movements (as cited in Gratwick 1993 , ad loc.).

Incidentally, color is not really the sole issue. In his commentary on Hippocrates’ passage Galen (AD 129- c.200/c.216) points out that color implies taste, clarity or consistency ( systasis ), odor, and strength. For him, “dark” ( melas ) wine is usually muddy ( pachys ). Indeed we might well translate the two adjectives as “clear” and “muddy” respectively. This ambiguity explains why Menaechmus finds the question so bizarre. Latin album and atrum do mean “clear” and “muddy,” but very rarely—only one attestation apiece, and both very late (Apicius 1.6 and Palladius 11.14.9 respectively). Moreover, “dark” wine in Latin is usually nigrum , not atrum (Fantham 2007 , 2011 ). Baffled, Menaechmus naturally takes the two words to mean literally “white” and “black”—like Crayola colors as it were. (Since the wordplay on melas works better in Greek than in Latin, I assume it derives thence and not, as so often elsewhere, from the wellspring of Plautus’ imagination.)

Zanini ( 1984 ) nearly got this idea in identifying the two central themes of Plautus’ play as “ simillimi” (identicals) and “ insania ,” but missed the epistemological point that unites them.

Sextus Empiricus Adv. Math . 7.408–410, Cicero Acad . 2.54–8 and 2.84–7. I am grateful to my colleague Charles Brittain for help on this point.

Burzacchini, G. (2007). Sull’ignoto modello greco dei Menaechmi . In R. Raffaelli & A. Tontini (Eds.), Lecturae plautinae sarsinates X: Menaechmi (pp. 11–19). Urbino: QuattroVenti.

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Fantham, E. (2011). The Madman and the Doctor. In E. Fantham (Ed.), Roman readings (pp. 15–31). Berlin: De Gruyter.

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Dedicated to the memories of David L. Rosenhan (1929–2012) and Thomas S. Szasz (1920–2012).

Note on text and translation Translations of Menaechmi in this paper are adapted at whim from those of Erich Segal ( 1996 ) and Paul Nixon ( 1917 ). The corresponding Latin text (which I have independently checked) is basically that of Friedrich Leo ( 1895 ).

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Fontaine, M. On Being Sane in an Insane Place – The Rosenhan Experiment in the Laboratory of Plautus’ Epidamnus. Curr Psychol 32 , 348–365 (2013). https://doi.org/10.1007/s12144-013-9188-z

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May 1, 2012

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Psychiatry's "Bible" Gets an Overhaul

Psychiatry's diagnostic guidebook gets its first major update in 30 years. The changes may surprise you

By Ferris Jabr

Editor's Note: Read our blog series on psychiatry's new rulebook, the DSM-5.

In February 1969 David L. Rosenhan showed up in the admissions office of a psychiatric hospital in Pennsylvania. He complained of unfamiliar voices inside his head that repeated the words “empty,” “thud” and “hollow.” Otherwise, Rosenhan had nothing unusual to report. He was immediately admitted to the hospital with a diagnosis of schizophrenia.

Between 1969 and 1972 seven friends and students of Rosenhan, a psychology professor then at Swarthmore College, ended up in 11 other U.S. hospitals after claiming that they, too, heard voices—their sole complaint. Psychiatrists slapped them all with a diagnosis of schizophrenia or bipolar disorder and stuck them in psychiatric wards for between eight and 52 days. Doctors forced them to accept antipsychotic medication—2,100 pills in all, the vast majority of which they pocketed or tucked into their cheeks. Although the voices vanished once Rosenhan and the others entered the hospitals, no one realized that these individuals were healthy—and had been from the start. The voices had been a ruse.

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The eight pseudopatients became the subject of a landmark 1973 paper in Science , “On Being Sane in Insane Places.” The conclusion: psychiatrists did not have a valid way to diagnose mental illness.

Rosenhan’s experiment motivated a radical transformation of the essential reference guide for psychiatrists: the Diagnostic and Statistical Manual of Mental Disorders (DSM) , published by the American Psychiatric Association (APA). The revamped DSM , dubbed DSM-III and published in 1980, paired every ailment with a checklist of symptoms, several of which were required for a diagnosis to meet the book’s standards. Earlier versions of the DSM contained descriptive paragraphs that psychiatrists could interpret more loosely. This fundamental revision survives today.

The APA is now working on the fifth version of the hefty tome, slated for publication in May 2013. Because the DSM-IV was largely similar to its predecessor, the DSM-5 embodies the first substantial change to psychiatric diagnosis in more than 30 years. It introduces guidelines for rating the severity of symptoms that are expected to make diagnoses more precise and to provide a new way to track improvement. The DSM framers are also scrapping certain disorders entirely, such as Asperger’s syndrome, and adding brand-new ones, including binge eating and addiction to gambling.

In the past the APA has received harsh criticism for not making its revision process transparent. In 2010 the association debuted a draft of the new manual on its Web site for public comment. “That’s never been done before,” says psychiatrist Darrel Regier, vice chair of the DSM-5 Task Force and formerly at the National Institute of Mental Health. The volume of the response surprised even the framers: 50 million hits from about 500,000 individuals and more than 10,000 comments so far.

Critics swarmed the drafts. Some psychiatrists contend that the volume still contains more disorders than actually exist, encouraging superfluous diagnoses—particularly in children. Others worry that the stricter, more precise diagnostic criteria may inadvertently give insurance companies new ways to deny medication to patients who need it.

The debates surrounding the manual’s revisions are not merely back-office chatter. Although many psychiatrists do not sit down with the DSM and take its scripture literally—relying instead on personal expertise to make a diagnosis—the DSM largely determines the type of diagnoses clinicians make. Insurance companies often demand an official DSM diagnosis before they pay for medication and therapy. Many state educational and social services—such as after-school programs for kids with autism—also require a DSM diagnosis. Consequently, psychiatrists cannot dole out diagnoses of their own invention. They are bound to the disorders defined by the DSM .

Therefore, psychiatrists cannot ignore the new manual and go about business as usual. They must adapt, especially if they want to be sure that their patients keep receiving affordable treatment. Yet this diagnostic bible is a work in progress. In fact, although the revisions are 90 percent complete, the APA may still make significant changes and even delay the book’s official release. Even after its publication, the DSM will remain a snapshot of a field in flux—an ambitious attempt to capture an evolving, often ambiguous science.

Diagnosing the DSM Psychiatrists have been kicking around the DSM-5 in a scientific scrimmage that dates back to 1999, when the APA and the NIMH sponsored a meeting to jump-start planning. More than 13 joint conferences later, committees of psychiatrists and psychologists have churned out dozens of white papers outlining how best to overhaul psychiatry’s bible. In April 2006 the APA appointed clinical psychologist David Kupfer and Regier as chair and vice chair, respectively, of a team of 27 scientists assigned to digest the research literature and propose revisions to this historic volume.

Right away researchers fingered several major failings of the DSM-IV . First, many of the symptom checklists were so similar that many patients left a psychiatrist’s office with several official diagnoses rather than just one. It is unlikely that large numbers of patients each have a variety of different disorders, says Steven Hyman, a task force member. Rather, he suggests, a single cognitive or biological process—maladaptive thought patterns, for instance, or atypical brain development—may manifest itself in symptoms of more than one ailment. To address this problem, curators of the new book eliminated over a dozen less distinct disorders, in some cases merging them into larger categories of illness, such as the autism spectrum [see “ Psychosis Revisited ”].

Patients and their psychiatrists often struggle with the opposite problem, too: a person’s symptoms might be fewer or milder than those listed in the DSM or simply do not match any disorder in the manual. As a result, psychiatrists slap large factions of their clientele with a “disorder not otherwise specified” label. The most frequently diagnosed eating disorder is “eating disorders not otherwise specified.” The predominant autism spectrum disorder? By most estimates it is “pervasive developmental disorder not otherwise specified.” The third most common personality disorder is, you guessed it, “personality disorder not otherwise specified.” Health professionals rely so heavily on catchall diagnoses because the current DSM has some serious gaps in its diagnostic offerings and has some superfluous entries.

In addition to eliminating ailments, the DSM-5 will encourage psychiatrists to collect more detailed information about patients’ symptoms. With more data to consider and more complete descriptions in the manual, the theory goes, psychiatrists are more likely to find a proper match between a patient and an illness.

Degrees of Dysfunction To improve diagnoses, the DSM-5 asks doctors to grade the severity of their clients’ symptoms. A verdict of major depression, for example, will include a rating for each symptom—insomnia, say, or thoughts of suicide. Similarly, a child who is diagnosed with attention-deficit hyperactivity disorder would also receive an assessment of her ability to focus, ranging from poor to excellent.

This ideological shift signals a step away from the simplistic notion that mental illnesses are discrete conditions wholly distinct from a healthy state of mind. Instead the new volume reflects the idea that everyone falls on a spectrum that stretches from typical behavior to various shades of dysfunction. Where you land on that scale determines whether your symptoms merit treatment. This approach might assist, for example, psychiatrists evaluating a patient’s attention problems, which can seem almost ubiquitous in younger children. Considering an individual in the context of others can make it easier to flag the neediest cases. Psychiatrists, of course, already use many scales and questionnaires in their practice. The DSM-5 will standardize such ratings so that doctors use the same scales to measure a given disorder and increase the chances they will reach similar conclusions about comparable patients.

These detailed assessments should allow treatments to become more tailored. For example, a patient with mild signs of depression is more likely to benefit from therapy and lifestyle changes than from antidepressant medication, which recent findings suggest is more effective for severe depression. Psychiatrists and patients will also gain a new way to track improvement. A shift in the depression gauge from “severe” to “moderate” may in itself lift a patient’s spirits, motivating him to stick to the regimen propelling his progress.

Although most psychiatrists support the idea of measuring severity, practitioners have also voiced various concerns. Placing several previously distinct disorders under the umbrella of autism, for example, has ignited fears that autistic people with less severe symptoms will no longer qualify for a diagnosis or treatment. Questions have also been raised about how insurance companies will respond: Could these scales create barriers to treatment? A simple diagnosis of depression may no longer be enough to qualify a patient for anti­depressants—insurance companies may demand that a patient’s depression meet a certain severity level.

The new procedures will require patients to complete more evaluations and surveys than ever before, culminating in larger amounts of paperwork and more time spent on every diagnosis. Some psychiatrists worry the extra effort will deter their peers from using the DSM properly—and a few have even proposed doing away with the severity ratings altogether. More broadly, psychiatrists have also objected to the addition of certain disorders that they consider dubious.

A Primitive Guide? A second sweeping change to the DSM is the way it clusters disorders. The DSM-IV was organized around three categories of illness. One group captured all major clinical disorders, such as depression, bipolar disorder and schizophrenia. Another section encompassed all personality and developmental disorders. The third category contained “medical” problems that might play a role in mental illness: diabetes or hypothyroidism, for instance, can exacerbate depression. The DSM-5 throws these relatively arbitrary divisions out the window. Instead it arranges diseases chronologically, starting with illnesses that psychiatrists typically diagnose in infancy or childhood—such as neurodevelopmental disorders—and moving toward those frequently found in adults, such as sexual dysfunctions. When evaluating a toddler, for instance, a psychiatrist can focus on the front of the DSM-5 or the beginning of a chapter, say, on depressive disorders, where he or she will find the types of depression most likely to afflict children.

As genetic and neuroimaging studies improve our understanding of the relations among ailments, the DSM will be able to swiftly adapt. The APA plans to publish the new manual in print and as a “living” electronic document that can be updated frequently as version 5.1, 5.2, and so on. (The APA dispensed with Roman numerals to make this labeling practical.)

Eventually researchers aim to root the DSM in the biology of the brain. Someday scientists hope to find useful “biomarkers” of mental illness—genes, proteins or patterns of electrical activity in the brain that can serve as unique signatures of psychiatric problems. Lab tests based on such markers would make diagnosing mental illness easier, faster and more precise.

“The DSM has always been a primitive field guide to the world of psychological stress because we know very little about the underlying neural chemistry of psychological symptoms,” says psychiatrist Daniel Carlat of the Tufts University School of Medicine. “But over the past 60 or 70 years the categories have become more reliable and meaningful.” No one argues that the DSM flawlessly mirrors mental illness as people experience it, but every revision sharpens the reflection—and with it, people’s understanding of themselves. 

MORE ON THE DSM-5

Fast Facts: A New Guide to Your Psyche 1.The fifth version of psychiatry’s bible, the Diagnostic and Statistical Manual of Mental Disorders , slated for publication in May 2013, represents the first substantial change to psychiatric diagnosis in more than 30 years.

2.In 2010 the American Psychiatric Association debuted a draft of the new manual on their Web site that has so far received 50 million hits from about 500,000 individuals, many of them critics.

3.The revised manual will very likely scrap psychiatry staples such as Asperger’s syndrome and paranoid personality disorder.

4.Additions to the diagnostic menu are likely to include an ailment for children marked by severe temper tantrums and for adults a type of sex addiction.

Psychosis Revisited Schizophrenia is characterized by a tenuous grasp of reality, difficulty thinking and speaking clearly, and unusual emotional responses. In today’s diagnostic manual, the DSM-IV , this complex disorder is split up into the following “types”:

Paranoid: delusions and auditory hallucinations but normal speech and emotional responses.

Disorganized: erratic speech and behavior and muted emotions.

Catatonic: unusual postures and movements or paralysis.

Residual: very few typical symptoms but some odd beliefs or unusual sensory experiences.

Undifferentiated : none of the other types.

Yet another form of the illness is shared psychotic disorder: when someone develops the same delusions as a friend or family member with schizophrenia.

Soon you can forget all these variants. As with certain personality disorders, there is little evidence for the existence of these discrete categories. Catatonia, for instance—an intermittent “freezing” of the limbs—also accompanies bipolar disorder, post-traumatic stress disorder and depression. Therefore, psychiatrists say it makes little sense to call it a form of schizophrenia. Catatonia also does not respond well to the antipsychotic medications used to treat schizophrenia.

Even as it sheds these subtypes, the DSM-5 embraces novel forms of psychosis. The most contentious is attenuated psychosis syndrome, a cluster of warning signs that some researchers think precede the frequent delusions and hallucinations that characterize the full-blown disorder. Its purpose is to catch young people at risk and prevent this insidious progression. Critics contend, however, that two thirds of the children who qualify for the at-risk criteria never develop real psychosis and may unnecessarily receive powerful drugs [see “At Risk for Psychosis?” by Carrie Arnold; Scientific American Mind , September/October 2011]. After all, about 11 percent of us sometimes hear voices or engage in moments of intense magical thinking with little or no distress.

Another controversial addition is disruptive mood dysregulation disorder, a diagnosis for kids that carries less stigma than its predecessor, childhood bipolar disorder. Since about 2000, diagnoses of pediatric bipolar disorder have jumped at least fourfold in the U.S. Many psychiatrists, however, argued that their peers were mislabeling a condition that was not bipolar disorder at all and treating children with strong drugs before knowing what really ailed them.

Very few people younger than 20 develop true bipolar disorder, in which moods swing between depression and mania. The vast majority of the kids who received the label did not, in fact, oscillate in this way. Instead they were in a bad mood all the time and frequently exploded in anger and physical violence, even in response to a minor offense. Because of these differences, disruptive mood dysregulation disorder describes a child (younger than 10) who is constantly irritable and has extreme temper tantrums about three times a week.

The APA says this pediatric entry will “provide a ‘home’ for these severely impaired youth,” but some critics worry doctors will dole out the diagnosis like lollipops to droves of tantrum-prone toddlers. The treatment is the same, despite the new name: a mixture of mood stabilizers, antipsychotics, anti­depressants and stimulants. —F.J.

Personality Problems To a psychologist, a personality consists of persistent patterns of thought, emotion and behavior. Someone with a personality disorder has rigid and dysfunctional patterns that disrupt his or her ability to maintain healthy relationships. The current encyclopedia of mental illness, the DSM-IV , describes 10 such conditions. These include paranoid personality disorder—the inability to trust others and an irrational belief that people are out to get you—and narcissistic personality disorder, an exaggerated sense of self-importance, a need for constant admiration and excessive envy of others.

Suspiciously, between 40 and 60 percent of all psychiatric patients are diagnosed with a personality disorder, hinting that symptoms of at least some of these “disorders” resemble typical behavior too closely. In addition, psychiatrists often diagnose the same patient with more than one ailment, suggesting significant overlap. For example, people with both histrionic and narcissistic personality disorders insist on being the center of attention, take advantage of their families and friends, and have trouble reading others’ emotions.

The upshot: DSM-5 ’s editors nixed histrionic personality disorder. Paranoid, schizoid and dependent personality disorders are also gone. Your personality can still, however, be narcissistic, antisocial, avoidant, borderline, obsessive-compulsive or “schizotypal.”  —F.J.

Good-bye to Asperger’s? Certain behavioral quirks have long been thought to distinguish Asperger’s syndrome from other autistic disorders. “Aspies,” as people with this affliction sometimes call themselves, tend to develop intense fascination with very specific objects or facts—the wheels of toy cars or the names of constellations—in the absence of a general interest in, say, automotive mechanics or astronomy. Now the diagnosis will disappear, and Aspies may find an important part of their identity stripped away.

Currently Asperger’s is one of five so-called pervasive developmental disorders, along with autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), and the lesser-known Rett syndrome and childhood disintegrative disorder (CDD). All these problems are characterized by deficits in communication and social skills as well as by repetitive behaviors. Indeed, the APA has decided that four of the five disorders—autistic disorder, Asperger’s, CDD and PDD-NOS—are so similar that they should all be placed into a new category called autism spectrum disorder (ASD). Psychiatrists using the new DSM will give anyone on the spectrum a diagnosis of ASD, along with a rating of illness severity.

Children whom psychiatrists would previously have diagnosed with CDD fall at the more severe end of the spectrum. They typically experience an almost complete deterioration of social and communication skills starting sometime between the ages of two and 10. Asperger’s patients will land on the milder end. They generally do not show language delays and, in fact, often display excellent verbal skills. Rett syndrome, in which known genetic mutations stunt physical growth, along with language and social skills, is gone from the manual entirely. Ironically, the APA is eliminating it because a genetic test for the condition makes diagnosis so precise and straightforward. For now the DSM prefers to limit itself to a blunter diagnostic measure: behavior.

Statistical studies published in 2011 and 2012 confirm that the DSM-5 criteria for autism are more accurate than those penned in the DSM-IV . The revised guidelines practically guarantee that anyone told they have the disorder really has it. To qualify as autistic by the new manual, a patient must meet five of seven symptoms—a higher bar than the six-of-12-symptom cutoff in the DSM-IV .

Some psychiatrists say the new rules are too strict: they worry some high-functioning autistic people, such those now diagnosed with Asperger’s, may not meet the criteria and may miss out on educational and medical services as a result. On the other hand, if people with milder autismlike symptoms do make it onto the spectrum, the lack of an Asperger’s label could benefit them. States such as California and Texas now provide educational and social services to people with autism that they deny to those with Asperger’s. Some parents argue, though, that limited resources should go to kids with more severe symptoms before anyone else. —F.J.

Craving Cash, Food and Sex Several new types of addiction may appear in the upcoming version of psychiatry’s bible, the DSM-5 . Gambling disorder is one. In the past decade studies have shown that people get hooked on gambling the same way they become addicted to drugs and alcohol and that they benefit from the same kind of treatment—group therapy and gradual withdrawal. Neuroimaging research has revealed that the brains of drug addicts and those of problematic gamblers respond to reminders of drugs and monetary rewards in similar ways: their reward circuits light up, much more than casual gamblers or one-time drug users. The DSM-5 may also include obsessions with food and sex:

Binge Eating Disorder Consuming “an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances” and lacking control over what, how much or how fast one eats.

Hypersexual Disorder Having unusually intense sexual urges for at least six months or spending excessive amounts of time having sex in response to stress or boredom, without regard for physical or emotional harm to oneself or others, de­spite the fact that it interferes with social life and work.

Absexual Disorder Feeling aroused by moving away from sexuality or behaving as though moralistically opposed to sex. As sex educator Betty Dod­son told Canadian news­paper Xtra! West, these are “folks who get off complaining about sex and trying to censor porn.” —F.J.

This article was published in print as "Redefining Mental Illness."

Ferris Jabr is a contributing writer for Scientific American . He has also written for the New York Times Magazine , the New Yorker and Outside .

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Why the Rosenhan Experiment still matters

Photo credit: Scott Barbour / Getty Images

• In 1973, eight experimenters faked insanity to see how easy it was to get into a mental hospital. The hard part was getting out.
• Their findings sparked a great debate over how psychiatry treated patients and how accurate diagnostic procedures were.
• In an age marked by a lack of proper mental health care, the finding that it was too easy to get a doctor’s attention seems shocking.

In the United States, mental health care can be difficult to come by. One-third of Americans live in a “ mental health professional shortage area ” and lack access to mental health facilities; this probably explains why less than half of the people who need treatment get it . It can almost seem like you have to be at the end of your rope to get help sometimes.

It didn’t use to be this way though; there was that one time that a psychologist found it was easier to fake your way into a mental hospital than it was to get out.

The Rosenhan experiment

In 1973, after hearing a lecture from the anti-psychiatry figure R.D. Laing the psychologist David Rosenhan decided to test how rigorous psychiatric diagnoses were at modern hospitals by first trying to get into them with fake symptoms and then trying to get out by acting normally.

Eight experimenters participated, including Dr. Rosenhan. All but two of them were somehow involved in medicine, so fake names and occupations were created to both avoid the enhanced scrutiny they expected members of their field to be given when claiming insanity and to prevent the test subjects from facing the stigmas of mental illness after the experiment ended.

The pseudopatients all reported the same symptoms, an auditory hallucination saying the words “empty,” “hollow,” and “thud.” These words were chosen to invoke the idea of an existential crisis. They were also chosen because, at the time, there was no literature on an “existential psychosis.”

Much to the pseudopatients’ surprise, they were all admitted to all 12 hospitals they went to with little difficulty. In all but one case, they were given a diagnosis of schizophrenia . In the outlier, a private hospital gave them a slightly more optimistic diagnosis of “ manic-depressive psychosis .”

Once admitted to the hospital, the patients were instructed to act normally and do what they could to be released. This led them all to be “paragons of cooperation” and to fully participate in ward life. They attended therapy, socialized with others, and even accepted their medications which they then disposed of. If asked, they were to say their symptoms had disappeared entirely.

Shockingly, the staff had no idea any of them were faking. Their normal behavior was medicalized into symptoms of their schizophrenia. For example, since all of the pseudopatients were taking notes on the hospital, naturally one of them had the note “patient engages in writing behavior” added to their file. Also, simply lining up early to get food was cited as an example of “oral-acquisitive” psychotic behavior.

The life details of the subjects, all fairly typical for the time, were suddenly signs of pathological behavior. One pseudopatient reported that he had a happy marriage though he occasionally fought with his wife and that he did spank his children on rare occasions. While this might seem like a standard 1960s life, his file read:

“His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings.”

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Schizophrenia’s Identity Crisis

Amusingly, while the staff at the hospitals had no idea they had fakers in the ward, the real patients often caught on very quickly. The participants reported dozens of cases of their wardmates coming up to them and accusing them of being either a journalist or professor playing sick in order to take notes about the hospital.

Disturbingly, the fakers also reported that the staff was dehumanizing and often brutal. Conversations with staff were limited by their frequent absence. When the staff did have time to talk, they were often curt and dismissive. Orderlies would often be both physically and verbally abusive when other workers were absent. The pseudopatients reported they often felt invisible, as the staff would act like they weren’t even there. These details were made worse by the powerlessness felt by the pseudopatients , which was reinforced both by hospital hierarchy and then current law.

Despite all the evidence that the experimenters were faking it, the shortest stay lasted a week, and the longest was 52 days. The typical stint lasted almost three weeks. All of the patients diagnosed with schizophrenia were deemed “in remission” upon being discharged, leading Dr. Rosenhan to write:

“At no time during any hospitalization had any question been raised about any pseudopatient’s simulation. Nor are there any indications in the hospital records that the pseudopatient’s status was suspect. Rather the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be ‘in remission’; but he was not sane, nor, in the institution’s view, had he ever been sane.”

Dr. Rosenhan concluded that, “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.” He was forgiving, however, and noted that at least some of the problem could be attributed to a desire to err on the side of caution and admit a potential faker with only one reported symptom before letting somebody in serious need of treatment go without.

He went on to explain how another hospital challenged him to send an actor which they would then identify. After presenting him with their lengthy list of suspected actors they had admitted, Dr. Rosenhan revealed that he hadn’t sent anybody at all. He saw this as further evidence of his conclusion.

How did people take this report?

The report, published in Science , was a minor bombshell that landed on a profession that was already reevaluating its methods in the wake of a society suddenly coming to grips with the conditions of mental asylums, an increasing number of findings that suggested institutionalization wasn’t the only way to treat mental illness, and the discovery by a group of British shrinks that American doctors were handing out diagnoses of schizophrenia left and right when other conditions were really at work .

When the Diagnostic and Statistical Manual of Mental Disorders , the big book of mental illnesses and their symptoms, was updated in 1980 for its third edition, the debate around Rosenhan’s experiment likely motivated the authors to make the symptom descriptions used to define various conditions more stringent .

What’s the catch? There has to be a catch with a study like this.

The methods of this experiment were questioned immediately, as they are atypical at best and unscientific at worst.

Physician Fred Hunter pointed out in his letter to Science that if the patients were acting “normally” during their stays, they would have revealed their lie and asked to leave shortly after arriving. He also criticized both the methods and the findings of the stunt. Psychiatrist Robert Spitzer also dismissed the whole thing as pseudoscience in a strongly worded academic article.

There is also the question of whether the conclusion is meaningful at all. Neuroscientist Seymour S. Kety pointed out that a similar stunt in an emergency room would hardly be considered a groundbreaking study, given how important honest reporting is in medicine:

“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.”

The continuing problems of dehumanization and deinstitutionalization

The findings of the study on how the mentally ill were treated, even in cases where they were paragons of cooperation, was widely accepted as a valid and needed critique. Even Dr. Hunter admitted that Rosenhan’s experiment did a good thing by exposing these horrors. Regrettably, today we still have need of Rosenhan’s reports on this subject.

In the United States, sixteen percent of people in jails have a mental illness . This is three times as many people as are seeking care for these conditions in hospitals and is creating new forms of institutionalization . The stigma around mental illness remains as strong as ever . While many people think the mentally ill are dangerous, statistics show they are much more likely to be the victims of violence themselves rather than hurt anybody else .

It seems that Dr. Rosenhan’s lament that “The mentally ill are society’s lepers” has yet to be made obsolete by progress.

Are there any other experiments like this? Could this have just been a disturbing blip?

Depressingly, this isn’t the only experiment to use these methods to conclude that how we treat mental illness needs work. In 1887, almost a century before Rosenhan’s article, Nellie Bly faked insanity to enter the Woman’s Lunatic Asylum in New York City. The book she wrote about her experience, Ten Days in a Madhouse , revealed the horrific conditions in the hospital and led to an inquiry that resulted in increased funding and more rigorous standards .

Modern attempts to recreate the study have shown some changes in the field of psychiatry. In 2001 , seven people who had schizophrenia presented themselves to intake offices in search of treatment; all of them were denied care due to lack of resources. In 2004, writer Lauren Slater claimed to have repeated Rosenhan’s experiment herself but was only given medication to go with her quick diagnosis. If she actually carried out this experiment remains a subject of debate .

Psychiatry has improved dramatically since the days of One Flew Over the Cuckoo’s Nest and David Rosenhan’s stings. Studies have shown the objectivity of psychiatric diagnoses remains comparable to that of the rest of medical science while acknowledging that some subjectivity is inevitable. Better methods of integration have made it difficult to tell who has a diagnosed mental illness and who doesn’t in normal circumstances. Deinstitutionalization has improved the lives of many people who would otherwise be locked away.

But while asylums are largely gone, there is still much work to be done. Rosenhan’s experiment will continue to remind us that being labeled as crazy can lead to a dehumanization with consequences just as isolating as any mental illness.

The Rosenhan Study Never Proved Anything Anyway

David rosenhan's 1973 study has come under attack, but what did it really show.

Posted November 4, 2019 | Reviewed by Abigail Fagan

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David Rosenhan's infamous 1973 study "On Being Sane in Insane Places" has been in the news lately. The original study, published in the prominent journal Science, involved Rosenhan, a Stanford University psychologist, and several other healthy "pseudopatients" feigning psychotic symptoms to gain admission to hospitals in five U.S. states.

Since Rosenhan and the others were diagnosed as mentally ill by the psychiatrists who examined them, Rosenhan confidently concluded, "It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals." The study went on to be interpreted as an invalidation of psychiatry, and its diagnosis, as a whole.

Now, a recent book titled The Great Pretender by Susannah Cahalan alleges Rosenhan fabricated his data. Regardless of whether Rosenhan was guilty of fraudulent research, one thing is clear: The Rosenhan study never proved anything in the first place. Even the psychiatrist Szasz, grouped alongside Rosenhan as an "antipsychiatrist" (a term Szasz abhorred), knew the study was nonsense. The whole thing was based on deceit.

Actually, the only thing the study showed was that it is possible to deceive doctors by lying to them. But this is nothing new: most of us learn this by the time we're in grade school, faking symptoms to avoid school or other childhood responsibilities.

What does any of this have to do with the legitimacy of psychiatry or the reality of mental illness? Plenty of medical diseases—readily identified as such—are diagnosed on the basis of symptoms (patients' subjective complaints). Anyone can walk into a doctor's office, complain of an inability to sleep, and be diagnosed and treated for insomnia . Similarly, migraine disorder, fibromyalgia , chronic pain, and a whole host of other real physical conditions are diagnosed on the basis of the patient's subjective report.

The most blatant problem with Rosenhan's study was that his "pseudopatients" were not pseudopatients at all—they were real patients faking real disease. The fact that some patients fake mental illness and are able to deceive the doctors who examine them says nothing about the legitimacy of the illnesses themselves.

The neuroscientist Seymour S. Kety, quoted by DSM -III chair Robert Spitzer, put it best: "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."

Nevertheless, Rosenhan’s study was published at a time when society was ripe for its conclusions. Szasz’s 1961 book The Myth of Mental Illness had become a bestseller, and psychiatry was beginning to look silly with claims by prominent psychiatrists that it had answers to all sorts of social ills from racism to war to poverty. This, combined with the fact that psychiatry still deemed homosexuality to be a mental disorder, left society seriously questioning the legitimacy of the field as a whole.

Yet a commonsense look at Rosenhan's study reveals that it didn't really show anything surprising at all. Some people can make others believe they are ill. But then again, any third-grader could tell you that.

Mark L. Ruffalo, M.S.W., D.Psa. , is an Assistant Professor of Psychiatry at the University of Central Florida College of Medicine and Adjunct Instructor of Psychiatry at Tufts University School of Medicine.

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