How reliable are psychiatric diagnoses is the question that was raised 30
years ago by David Rosenhan's renowned pseudo-patient study and raised again
by Lauren Slater's account of her own replication of that study in her book
Opening Skinner's Box: Great Psychological Experiments of the 20th
Century.
But psychiatrist Robert Spitzer, M.D., and other psychiatrists and mental
health professionals are skeptical of Slater's account. To test the validity
of Slater's account, they presented a sample of emergency room psychiatrists
with a vignette description of a hypothetical case that matched Slater's
account of how she presented herself at nine emergency rooms.
An e-mail was sent to 431 members of the American Association of Emergency
Psychiatry with a note from its president urging them to participate in a
study of psychiatric diagnosis and evaluation conducted by unnamed researchers
at the New York State Psychiatric Institute. The note said that to reveal the
purpose of the study would potentially bias the answers, but that the purpose
would be posted on the association's Web site when the study was completed. A
link to the study's Web site and questionnaire was provided. All responses
were anonymous.
Study participants were asked to consider the following case:
A married woman in her 30s comes to the emergency room complaining of
hearing a voice outside her head saying the word `thud.' She seems surprised
when another psychiatrist tells her that she looks `quite depressed,' and she
denies all symptoms of depression. She appears not to have brushed her teeth
or showered and wears a T-shirt that says, `I Hate My Generation.' She says
her appetite is good, her sleep is normal, and her work proceeds as usual. She
says that she is able to take care of her child.
Participants were then asked the following questions: What diagnosis(es)
would you write on the chart? Would you hospitalize the patient? If no, would
you refer the patient to an outpatient clinic? Would you prescribe medication?
If yes, which medication(s)? Reason for medication(s). Is there anything else
you would do or say?
Of 74 respondents, 56 avoided a specific DSM-IVdiagnosis and
instead diagnosed either psychosis not otherwise specified (NOS) (39) or
indicated that a diagnosis could not be made (17); four diagnosed psychotic
depression; four made another diagnosis but indicated that the psychotic
depression needed to be ruled out. The remaining 10 made other specific
diagnoses. Sixty-three said they would refer to an outpatient clinic, and
those who said they would hospitalize the woman said it was for the purpose of
further evaluation to make a diagnosis. Twenty-five indicated they would
prescribe an antipsychotic; no one said they would prescribe an
antidepressant.