The author explains how self-perpetuating falsehoods can trap doctors, researchers, and mental patients, which is exactly what is happening with pain patients and opioids.
When she was 24, Susannah Cahalan developed a sudden psychosis. She grew paranoid — convinced her apartment was infested with bedbugs, that people were spying on her, that her boyfriend was cheating.
She started to believe she could age people with her mind. As she recounted in her 2013 bestseller, “Brain on Fire: My Month of Madness,” she received several misdiagnoses (bipolar disorder, schizoaffective disorder) before an alert doctor discovered the true culprit: autoimmune encephalitis.
The moment her illness was deemed neurological, ”as in physical, in the body, real,” rather than psychiatric, “in the mind and therefore somehow less real,” the quality of her care drastically improved, Cahalan writes in her new book, “The Great Pretender.”
This is so true of pain patients as well. My diagnosis of EDS has saved me from suffering the dismissive skepticism and downright disbelief of doctors. Now that I can point to a physical reason for my pain (and show reams of documentation from this blog), I don’t have to beg doctors to believe me.
Sympathy and understanding replaced the detached attitude that had defined her treatment as a mental patient, “as if a mental illness were my fault, whereas a physical illness was something unearned, something ‘real,’” she writes.
Cahalan, a journalist, recovered from her brief psychosis, but the distinction between physical and mental illness continued to perplex her.
The book centers on the work of David Rosenhan, a Stanford psychologist whose paper, “On Being Sane in Insane Places,” was an instant sensation when it was published in the journal Science in 1973
Rosenhan went on to describe what happened when he sent eight healthy volunteers to psychiatric hospitals with a script. They were to say that they heard voices saying, “thud,” “empty,” and “hollow.”
This single complaint was enough to get each of these “pseudopatients” diagnosed with a mental illness (usually schizophrenia) and admitted into 12 different psychiatric hospitals across the country.
Once inside, they ceased the charade and resumed their normal behavior, yet none were ever detected as frauds. (According to Rosenhan, they were released when their mental illnesses were deemed “in remission.”)
“Having once been labeled schizophrenic, there is nothing the pseudopatient can do to overcome the tag,” Rosenhan wrote
This sounds very similar to what happens to pain patients if some doctor writes in their chart that they are “drug-seeking” or “diagnoses” them as addicted to their pain medication.
Columbia University psychiatrist Robert Spitzer was a fierce critic of Rosenhan’s paper but he recognized that the publicity storm created by Rosenhan’s work could help him get traction for his effort to improve the American Psychiatric Association’s approach to diagnosing mental illness.
Cahalan’s book is a sharp investigation into how human self-interest, weaknesses, and egos can shape the way that science proceeds.
The largest force shaping science these days is money chasing a popular misconception that opioids are dangerous and even unnecessary. Only studies looking for negative effects of opioids are funded and data is “tortured” until it shows what the funding party desires. Otherwise, it usually remains unpublished and no further study is funded.
Rosenhan’s study was small — only eight subjects — and as Cahalan digs deeper into the details, she finds that not all was as Rosenhan reported it.
But even though she ultimately concludes that Rosenhan misrepresented and probably even fabricated some of the data reported in his study, Cahalan is more interested in exploring the repercussions of Rosenhan’s work than in tearing down the man himself.
Even as she decides that he’s an unreliable narrator, she considers him the bearer of a worthy cause. “In the end I believe that [Rosenhan] exposed something real,” Cahalan writes. This something was
- the ways that psychiatric conditions are dismissed as less legitimate than physical ones,
- the stigmatization of the mentally ill, and
- the limitations of psychiatry’s diagnostic tools.
These problems remain worthy of attention, she writes, even if “the messenger was not.”