In 1973, David L. Rosenhan conducted an experiment to check the validity of diagnosis in mental health institutes; more particularly, psychiatric wards. What he did was send eight mentally healthy individuals, with no past history of mental illness, to 12 psychiatric clinics and hospitals at different levels – rural, urban, government, and private. One of the eight “pseudo-patients” was Rosnehan himself. All of them presented a typical case of auditory hallucination. 7 of them were diagnosed with Schizophrenia, and 1 with Manic-Depressive psychosis. All were admitted to the wards, for 7-52 days (average 19 days). It was surprising that despite behaving normally after admission, none of the pseudo-patients were “caught” by the staff. 35 out of 118 real patients in the various wards did suspect the experimenters to be “sane” and had, on certain occasions, warned the staff that they may be journalists or professors. None of them were believed. This led to the famous paper “On Being Sane in Insane Places”.
Psychology has often questioned the need for a diagnostic label in the first place. Supporters might have you believe in its necessity for simplifying communications within staff, for research purposes and for easy references. But to be honest, it is not as simple as it seems in practice. I didn’t really understand this difference, until I interned at the psychiatric division of a state-run college-cum-hospital.
Of the many interesting cases that I had witnessed during my internship, the case of Mr. X was a particularly unique one. Mr. X was a 25-year old mechanic who lived with his grandfather and his elder sister. His mother died young. When X was 7-years old, his father remarried and sent the children away to the grandparents’. Although not very economically well-off, the grandfather took particular care in fulfilling X’s demands. When I met Mr. X, he quietly lied on his bed, with his grandfather sitting next to him. He had deep, visible cut marks all over his arms, chest and stomach. Looking tired, he described his condition to me. “I saw them, the people with swords coming to kill me. So I freaked. I hurt myself and started shouting at them to take my blood. Somehow, the sight of my own blood calmed me down.” There were only few fresh cuts on his hands. The rest of them were old signs.
It was clear, on being brought on to the psychiatric ward, that he had visual hallucinations. Temporarily being diagnosed with schizophrenia, he was admitted to the hospital. I had several occasions to talk to him and his grandfather. “If only his father would not have left him early, maybe he would have been in a better condition”, the grandfather would often cry stating this. It was heart-wrenching to see such an old man sitting by his grandchild’s bed, day in and day out. Mr. X, too, showed repentance. “I couldn’t give back anything to my grandfather. I have become so sick. I regret asking for the motorbike”.
Motorbike? What was that about? Being the only undergraduate, I could only find out about this through word-of-mouth whispers of the senior interns, who, too, hadn’t dealt with him directly. Two years back, he had an accident while riding his motorbike. Despite several attempts, his left leg could not be treated fully. As a result, he had a permanent limp, limiting his working capabilities. It evoked nothing but sympathy from us.
Now, every Thursdays, the hospital would hold case presentations where complicated cases would be discussed. One fine week, it was Mr. X’s turn. All the senior professors, including the Head of the Department, were present for the discussion. The case presentation did not have anything that I wasn’t aware of, except perhaps, another tentative diagnosis of borderline personality. While most of the senior professors were in discussions, it was the HOD who sprang up with his questions. “Wait! Can you describe the marks on his hands and stomach?” What followed was nothing short of a thriller movie for me, being a novice intern.
As it turns out, the marks on his body were only deep enough to bleed and leave a sign, but not as grave as to prove fatal for him. Moreover, there were no marks on his face or his back. Although the back was not reachable, leaving the face out, when none of his other body parts were missed, things seemed fishy. When the patient and his caretaker arrived, the case became much more focused than before. When X was 22-years old, he had demanded a motorbike, to which his grandfather had refused to comply. On being denied his wish for the first time, he had slashed his hands and let out his blood. This horrified his grandfather, who then, took on a loan to get his dear grandson a bike. A year after that, X had the accident, crippling him for life. His friends and neighbours started teasing him. Unable to bear the taunts, he attempted his first suicide. Or at least, that is what he wanted others to believe, until the HOD caught the gaps in between. Once the patient was interrogated and sent back, the HOD pointed out that X’s first suicide attempt was in a room, with a fully open window. Through this, people passing by saw him and saved him from the act. His second attempt at suicide was using his elder sister’s silk saree. Silk being a slippery material quickly unfolded and dropped him to the ground, injuring his left leg again. Both these acts seemed more of a show, than real actions. But the instances had visibly scared the grandfather. So he began attending to each and every need of Mr. X. The HOD ended the discussion stating a high possibility that the accident itself might have been staged, because X was not happy with his job. It was doubted if X wanted to work at all.
In the context of Hysteria, Freud believed that every sick person, unconsciously, derives certain primary and secondary benefits because of the illness, which leads to its continuation. While the primary benefits may in the form of not having to work, escaping an unwanted situation, etc, the secondary benefits include being taken care of, provided for and so on. It is difficult to state whether the case of Mr. X was at a conscious level or at an unconscious level. Nevertheless, it should not be denied that he was suffering from a problem. Such cases bring on a good amount of jibes and jitters from the layperson. But in reality, we must understand that this coping mechanism of self-harm in order to manipulate others is, in itself, a harmful indulgence, that cannot be undertaken by any “sane and sorted” mind. It also forms one of the criteria to be classified under borderline personality. What was Mr. X’s final diagnosis, I didn’t know. My internship had terminated by then. But honestly, it was not even important to know. Whenever treatment is involved, it always tackles individual symptoms. There is no particular medicine or therapy for a particular disorder. There are only ways to tackle the symptoms. The circus of diagnosis is only used to give a label to the patient which every professional could recognize and act upon. Surely, it is an integral part. But any form of labeling lingers on. A person named Krisha diagnosed with schizophrenia will be identified, for her entire life, as a schizophrenic. “Oh! Krisha – that girl suffering from schizophrenia?”
This is problematic in itself when the whole process of diagnosis is so vague. DSM criteria are only separate on text, hardly in practice. How would one differentiate between manic-depressive with psychotic symptoms from schizophrenia, if the symptoms are so similar? And this would make a whole lot of difference because manic-depressive psychosis has a better course and prognosis than the latter. People also fake their disorder for conscious benefits (separate from the unconscious benefits of the real cases). Another patient I had met at the internship had successfully faked a disorder simply because she could be in a hospital where all her needs were being taken care of. She was caught only after 21 days into her second hospitalization. More than faking, perhaps a more serious issue here would be misdiagnosis. Rosenhan’s research is a classic example of this.
Thus, in Rosenhan’s words, “if sanity and insanity exist, how shall we know them?”