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

2. Announcements
Exam #1 is this Friday

3. 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

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

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

6. 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.

7. 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

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

9. 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

10. 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.”

11. 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?)

12. 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:
Rosenhan article was important part
Psychiatry’s responses to the anti-psychiatry movement, and current status

13. 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

14. Scientology and the “Anti-Psychiatry” Movement
Scientology: high-profile part of the anti-psychiatry movement today
Citizens Commission on Human Rights
CCHR’s “Psychiatry: An Industry of Death Museum”

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

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

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

18. 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

19. 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?

20. 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?

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

22. 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?

23. 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

24. “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)

25. 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?

26. “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)

27. 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?

28. 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?