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President Address


Presidential Address

Dr. M. Thirunavukarasu, MD 

          We, the generation living in the early years of the 21st century occupy a special position in human history, in that we have witnessed unprecedented and unparalleled growth in the understanding and knowledge about the world around us and life on this planet. While we bask in that glory, let us not forget that there are some important and large questions, that remain embarrassingly unanswered. The most conspicuous of those questions is one that is central to the field of psychiatry - ‘What is the mind?’. Nevertheless, psychiatrists have brazenly avoided or ignored this question due to a learned lack of enthusiasm, given the historical inability to achieve a consensus about anything pertaining to the mind. Not to mention the inevitable criticism and/or possible ostracism that relentlessly pursues anyone who takes a stand on this controversial issue. Psychiatrists didn't just want to open that can of worms! We simply hoped that if we managed to keep the can closed, the worms would suffocate and die and we would never have to face that uncomfortable question again. We believed that just like we managed to evade the exact definition of mental illness, we would be similarly successful in evading the definition of the mind. However in the last several decades, human life has transformed so much that we are now faced with a relatively new concept - mental health, which too remains to be defined. The list keeps growing and our silence has been deafening. While our understanding of the human brain, human behavior and neurosciences has grown exponentially, the task of describing or defining the mind has also become increasingly difficult. Our wilful indifference or tactical retreat from confronting these tough questions is not helping us, one bit. Increasingly, we are educating ourselves with an explanation that any definition of mind or mental health is not even a possibility, let alone plausibility. Let me highlight the importance of this issue by discussing the well-known, controversial, yet insightful Rosenhan experiment.



In 1973, American psychologist David L Rosenhan (Figure 1) published the findings of his controversial study, ‘On being sane in insane places’ in the journal Science, stirring up a lot of reactions and criticisms among the psychiatric community. It was a two-part experiment exploring the consistency and validity of traditional methods of psychiatric diagnoses. For the first experiment, Rosenhan arranged a group of 8 normal individuals called pseudopatients who were known to have no psychological or psychiatric pathology. They included a psychology graduate student, 3 psychologists, a pediatrician, a psychiatrist, a painter and a housewife. Three of them were women and five of them men. Rosenhan was one among them. These pseudopatients appeared at 12 different psychiatric hospitals (11 university or state hospitals and 1 private hospital), reporting a false complaint of repeatedly hearing something such as “thud”, or “hollow” or “empty” and gaining secret admission. They used pseudonyms (false names) to feign their real identity. However, other than this fabricated complaint of auditory hallucination, they reported no other problems and behaved completely normal, i.e. as they would usually behave. Rosenhan conducted this experiment to see if psychiatrists could correctly identify the pseudopatients with one fabricated symptom, as sane. To everyone’s embarrassment, all these patients were diagnosed with schizophrenia, except the one who appeared at the private institution who was diagnosed with manic-depressive psychosis. All of them were admitted into inpatient wards, with stay ranging between 7-52 days and averaging at 19 days. As instructed and planned prior to the study, these pseudopatients stopped complaining of the initial complaint soon after admission. They observed the condition and happenings inside the psychiatric hospitals keenly and took notes diligently. Initially their note-taking was secretive and discrete, but as soon they realized that no one else was paying attention, they started taking notes openly. They were cooperative, friendly and pleasant, and were also recorded in the hospital records as being so. Despite all this, none of them were identified as sane during the hospital stay. They were prescribed psychotropic drugs, which they reportedly discarded without the knowledge of the hospital staff. They were released with a discharge diagnosis of ‘schizophrenia in remission’, after they admitted to being insane but feeling improvement. Some of the results of Rosenhan's experiment came to be known to the staff of a certain teaching psychiatric hospital, which claimed that such errors would not happen at their institution. This claim formed the basis for the second part of the experiment. Rosenhan made an arrangement with this hospital, letting them know that he would send one or more pseudopatients (i.e. sane individuals) to their hospital in the next three month period to gain secret admission. Each staff (including attendants, nurses, psychiatrists, physicians and psychologists) were asked to rate each patient presenting for admission based on their suspicion of being a pseudopatient and thereby identify the impostors. During the three month period, 193 patients were judged and of these, 41 patients (~21%) were identified as pseudopatients by at least one staff member, while 23 patients (~12%) were identified as pseudopatients by at least one psychiatrist. Nineteen patients (~10%) were identified as pseudopatients by one psychiatrist and one other staff member. The results of this 2nd part of the experiment were more embarrassing than the first – Rosenhan reported that he had sent no pseudopatients to this hospital during that period.


From both these experiments, it can be suggested that traditional methods of diagnosis of mental illness were incapable of identifying, at least uniformly and consistently, even within one nation and one culture, sanity from insanity, and abnormality from normality. In the first experiment, psychiatrists committed a false positive diagnosis of a sane person as insane, i.e. what statisticians would call a type 2 error. That is to say, the psychiatrists erred on the side of caution by assuming disease in an healthy individual, rather than missing a serious diagnosis such as schizophrenia. This is understandable, given the style of training during medical education where assuming illness in a healthy person (in order to give the benefit of doubt and empiric beneficial treatment) is taught be more acceptable than missing a diagnosis of a potentially serious illness. In the second part of the experiment, when the staff were consciously alerted of the possibility of faking insanity, they tended to make numerous false negative diagnoses, i.e Type 1 errors. Due to a significant rate of Type 1 and Type 2 errors, the contemporary diagnostic method for mental illness was unreliable, Rosenhan concluded.


Rosenhan began this article in Science, with an open question, “If sanity and insanity exist, how shall we know them?”. Its been more than 35 years since this article was published. Do we have an answer for Rosenhan? No. Currently, each mental illness is identified by a set of presenting symptoms or elicited signs. This assembled set of clinical information invariably lends itself to variations arising from culture, language, geography, religion, country, etc from the view points of both the subject and the psychiatrists; not to mention the wide interpersonal variations and even temporal changes within the same person. Such variations are often resolved by a process of voting or consensus by a select group of experts. Criteria for diagnosis of mental illnesses are then statistically derived, most often by some sort of scoring system on list of enumerated symptoms for each diagnosis. The lack of these mental illnesses, is then understood to be mental health, by principle of diagnostic exclusion. Even the so-called positive definitions of the mental health seem to be constructed indirectly from exclusivity of what constitutes mental illness. Mind, on the other hand is commonly described as a conglomeration or array of a variety of psychological functions such as memory, learning, perception, consciousness, emotions, thought, reasoning, imagination, problem-solving, etc.


In my experience as a clinical and teaching psychiatrist for the last 30 years, I have found these definitions of mind and mental health minimally beneficial in educating medical students, psychiatry residents and fellows, mental health nurses and paramedics. These definitions are too broad and loose for educating mental health professionals, who are often left without any working definition of mind or mental health necessary for them to understand psychiatric patients and approach them in a comprehensive manner. They are also unable to understand the scientific literature and interpret them properly. Conversely, authors of scientific manuscripts also use terms interchangeably, adding to the confusion. The existing definitions give room for too much interpretation, misunderstanding and misspeaking of terms. Inevitably, it allows personal bias to creep into science, allowing for exploitation of the field by ideologies operating towards non-medical objectives. Psychiatrists

are also unable to explain to patients and the common public alike (especially in popular media) about mind or mental health without confusing the listeners. Worse is that psychiatrists often offer different, sometimes contrasting and rarely, even contradicting explanations, leaving the public to assume that psychiatrists do not know any more than the others about the mind. Such attitudes are widely prevalent, contributing to the pre-existing stigma in psychiatry. This also stalls progress in the attempts to increase mental health awareness. In essence, our delay in defining the core operating entity of our profession - the mind or the psyche, has not been beneficial. We have to act, and act now. 

President Address - Page 2

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