Discussion of “On Being Sane in Insane Places” article February 12, 2014 PSYC 2340: Abnormal Psychology Brett Deacon, Ph.D.

Announcements Exam #1 is this Friday

From Last Class Take-home messages from Lilienfeld’s talk Diagnosing mental disorders Types of classifications (categorical, dimensional, prototypical) Limitations of the DSM approach/issues in diagnosing mental disorders Evolution of the DSM Multiaxial system

For Today A few more words on diagnosing The “anti-psychiatry” movement Rosenhan article

Diagnosing Mental Disorders Primary role of mental health professionals Scientifically questionable but practically indispensable in our current healthcare system

Reliability and Diagnosis Reliability (interrater agreement). Affected by: Subjectivity of diagnostic criteria Patient report (accuracy, self-disclosure) Types of questions being asked by assessor Unstructured vs. structured interviews And test-retest reliability.

Validity and Mental Disorders Mental disorders overlap a great deal and are not separated by “natural boundaries” We have no objective tests to detect them Mental disorders are not categorically distinct from normality (i.e., mental health problems exist on a continuum) Thus, mental disorders are not valid in the traditional sense They are, arguably, useful by virtue of conveying information about cause, outcome, and treatment

Advantages of Diagnosing Enhances communication between professionals Facilitates study of causes and treatments of specific disorders Helps in treatment planning Necessary for insurance reimbursement

Disadvantages of Diagnosing Adds little to our understanding of a problem Diagnoses are not valid Many diagnoses have poor reliability Suggests the presence of a disease state Stigmatizes patients and invites discrimination

The “Anti-Psychiatry” Movement http://en. wikipedia (from Wikipedia) Two central contentions of the anti-psychiatry movement are that: “The specific definitions of, or criteria for, hundreds of current psychiatric diagnoses or disorders are vague and arbitrary, leaving too much room for opinions and interpretations to meet basic scientific standards.” “Prevailing psychiatric treatments are ultimately far more damaging than helpful to patients.”

Basis of The “Anti-Psychiatry” Movement History of abusive practices (eugenics, treatments) Stigmatizing, dehumanizing nature of psychiatric diagnoses Locating causes of mental disorder in the individual Pathologizing normality and/or social deviance Lack of evidence for biological disease theories Concerns about psychiatric medications Safety, efficacy, overuse, misinformation Corruption by pharmaceutical industry Forced hospitalization and treatment (based on?)

The “Anti-Psychiatry” Movement Anti-psychiatry movement gained momentum in 1960s (R.D. Laing, Thomas Szasz) One Flew Over the Cuckoo’s Nest won Oscar for Best Picture: http://www.youtube.com/watch?v=2WSyJgydTsA Rosenhan article was important part Psychiatry’s responses to the anti-psychiatry movement, and current status

Basis of The “Anti-Psychiatry” Movement Is it a “movement,” and if so, who belongs? Eclectic, loosely organized mix, including: “Psychiatric survivors” Journalists Academics, scientists Psychiatrists and other mental health professionals Organizations (e.g., MindFreedom) Scientologists

Scientology and the “Anti-Psychiatry” Movement Scientology: high-profile part of the anti-psychiatry movement today Citizens Commission on Human Rights http://www.youtube.com/watch?v=cc_wjp262RY http://www.youtube.com/watch?v=lhjdbifuNco&feature=results_main&playnext=1&list=PL03900CCD9B8BA031 CCHR’s “Psychiatry: An Industry of Death Museum”

Scientology and the “Anti-Psychiatry” Movement Is Scientology a “gift” to psychiatry? (Whitaker, 2010)

On Being Sane in Insane Places (Rosenhan, 1973) http://www. youtube

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.” -D.L. Rosenhan

Diagnosis and Stigma On being sane in insane places (Rosenhan, 1973) Issues to consider (1) how diagnoses were made (2) the effects of being labeled with a diagnosis (3) the effects of being a patient in a mental institution (4) personal reaction to the study

Rosenhan Paper This study was published Science, the most prestigious scientific journal in the world (and has been cited 2,143 times!) This was described as an experiment What was the hypothesis? What was the method? What were the results? What can we conclude from this study?

Rosenhan Paper How patients’ “normal” histories were interpreted How patients’ “symptoms” were interpreted Physical structure of the mental hospital Staff hierarchy and patient interaction “Overwhelming impression” of staff was that they “really cared,” “were committed” and “uncommonly intelligent” What it was like to be a patient in a mental hospital Depersonalization: lack of privacy, invisibility, abuse, extreme boredom, powerlessness Have things changed?

Rosenhan Paper Type 2 error, interpretation in this experiment Does schizophrenia “in remission” = currently insane, and always having been insane?

Spitzer’s (1976) critique Can psychiatrists accurately diagnose insanity? Three ways of assessing this: 1. Recognition that the pseudopatient is feigning insanity when he/she is first seen 2. Recognition, after observing behavior in the hospital, that the pseudopatient was initially feigning insanity 3. Recognition, during hospitalization, that the pseudopatient who initially appeared insane is no longer insane Relevance of #1 and #2 to the research question?

Spitzer’s (1976) critique 1. Why didn’t the psychiatrists initially detect that pseudopatients were feigning insanity? Rationale for schizophrenia diagnosis: what was the most likely diagnosis? Auditory hallucinations (empty, hollow, thud) Three weeks duration, greatly troubling at the outset Seeking admission into psychiatric hospital Absence of other explanations for symptoms, such as substance abuse, medical problems, or major precipitating stressors No obvious reason to suspect feigned illness and desire to be hospitalized

“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.” -Kety (1974)

Spitzer’s (1976) critique 2. Why, after observing their behavior in the hospital, didn’t the psychiatrists detect that pseudopatients were initially feigning insanity? Nature of schizophrenia: chronic and unremitting, or in some cases episodic with the possibility of quick recovery? Does all behavior of people with schizophrenia appear insane? What to make of appearance of normalcy? Did pseudopatients behave normally in the hospital?

“The pseudopatients did not behave normally in the hospital “The pseudopatients did not behave normally in the hospital. Had their behavior been normal, they would have walked into the nurses’ station and said, ‘Look, I am a normal person who tried to see if I could get into the hospital by behaving in a crazy way or saying crazy things. It worked and I was admitted to the hospital, but now I would like to be discharged form the hospital.’” -Hunter (1973)

Spitzer’s (1976) critique 3. Recognition, during hospitalization, that the pseudopatient who initially appeared insane is no longer insane Spitzer argues that this is the only method of detecting insanity that is relevant to the central question of the study What is the significance of being discharged with a diagnosis of schizophrenia “in remission?” How common is this? What do the results of this study actually show?

Current Status of Psychiatry Commitment to biological theories and techniques Assumption that biomedical research will lead to the development of biological diagnostic tests, and curative medications Crises: declining pharmaceutical company investment, exposure of drug industry corruption, increased public awareness of problems with brain disease theories and drug safety and effectiveness Momentum for the anti-psychiatry movement?