Robert M. Kaplan, MBChB, MA (Journ), MPhil (Sc), FRANZCP

This Month in Psychiatry: Looking Back to Look Forward

At the turn of the 20th century, general paralysis of the insane (

) was the scourge of psychiatry, regarded as a death sentence of the worst kind. The rapid descent into dementia was a tragedy for patients and their families. An effective cure was discovered in 1917 by Dr 

 The treatment involved infecting the patient with malaria; the resulting high fevers were believed to kill off the syphilis organisms. 

 rapidly spread to other countries, but Australian psychiatry did not appear to be in any rush to follow the trend.

 had a precipitous introduction to psychiatry, being the subject of a Royal Commission in 1925 on the basis of his efforts to improve conditions at 

. Exonerated, he was sent to Sunbury Hospital where he worked with Dr John Adey. Open to new ideas, Adey asked Ellery to try malariotherapy on a group of 10 GPI patients.

Several of the patients were too ill for the trial, reducing the number of participants to 6. A seaman with benign tertian malaria helpfully turned up at 

l and provided a blood specimen. On May 26, 1925, a male general with paresis “far gone in dementia and his doom sealed in a progressive paralysis” was subjected to the new treatment, followed by the other 5. Three patients had such a good response they could be discharged from hospital; the other 3 died.

Malariotherapy did not cure GPI, but it restored a virtually normal life to patients who otherwise faced death within a short time. Largely forgotten now, malariotherapy was swamped by decades of psychoanalysis.

 In contrast, malariotherapy led to a significant change in the relationship between psychiatrist and patient, ending the therapeutic nihilism that dominated psychiatric treatment for centuries.

Several decades later, Ellery said that to discharge 3 patients out of 10 “may seem a mere nothing,” but the importance lay in being able to administer treatment to those in whom “a lingering death was certain.” Malariotherapy was “the first plank over the moat” that separated mental hospital alienists from the rest of the medical profession.5 After this, psychiatry would never be the same.

is Clinical Associate Professor at the Graduate School of Medicine, Wollongong University and Research Fellow, History Department, Stellenbosch University, South Africa. He reports no conflicts of interest concerning the subject matter of this article.

1. Brown EM. Why Wagner-Jauregg won the Nobel Prize for discovering malaria therapy for general paresis of the insane. 

2. Ellery RS. On the treatment of general paralysis of the insane by malaria. 

A History of Psychiatry: From the Era of the Asylum to the Age of Prozac

Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century

Los Angeles: University of California Press; 1997.

The Cow That Jumped Over the Moon: Private Papers of a Psychiatrist. 

Articles

Treatment for "the scourge of psychiatry" involved malariotherapy-infecting the patient with malaria; the resulting high fevers were believed to kill off the syphilis organisms.

May 26, 1925: The First Malariotherapy Trial in Australia

Dr Eugen Bleuler became Director of the BurghÃ¶lzli Hospital in 1898. He attracted outstanding psychiatrists-including Carl Jung, Herman Rorschach, Ludwig Binswanger, and Karl Abraham-encouraging them to try new methods and tests. Determined to regard his patients as individuals, Bleuler made prolific notes, taking as much time as necessary to understand his patients.

On April 24, 1908, at the German Psychiatric Association meeting, Bleuler delivered a 

titled “Die Prognose der Dementia Praecox (Schizophreniegruppe).”

defined as a disease “characterised by a specific type of alteration of thinking, feeling and relation to the external world.”

Bleuler wanted to widen Kraepelin’s characterization of dementia praecox. He conceived of schizophrenia as a 

 His list of secondary symptoms, largely derived from psychoanalysis, implied an etiology. This was the critical difference with Kraepelin’s view: a disturbance or exaggeration of normal psychic function was light years away from his categorical distinction between psychosis and sanity.

originally denoted the diaphragm and later 

 It was capable of adjectivalisation and humanized the concept. The semantic distinction from Dementia Praecox was critical; Bleuler’s name derived from classical Greek with its focus on the nature of man.

However, the schizophrenia that Bleuler described was not free of problems. The secondary symptoms were difficult to define, open to misinterpretation, and fostered a purely psychological view of the condition.

Bleuler saw schizophrenia as an extension of normal personality that could, with perseverance, be understood and ultimately provide an insight into human nature. His classification was optimistic and gradualist, maintaining the option that it was ultimately a manifestation of the human condition.

Schizophrenia endures and will remain-in one form or another-as the Ã¼rword for psychiatry. To 

Tim Crow, “Schizophrenia is not just an illness of humans, it may be THE illness of humanity.”

 A century later, Bleuler would have good reason to be pleased with his creation.

is Clinical Associate Professor at the Graduate School of Medicine, Wollongong University and Research Fellow, History Department, Stellenbosch University. He wrote about Eugen Bleuler in his book

The Exceptional Brain and How it Changed the World 

Being Bleuler: the second century of schizophrenia

2. Bleuler E. (1950). Dementia praecox or the group of schizophrenias. International Universities Press.

‘Is schizophrenia the price that Homo sapiens pay for language?’

This month in history: Determined to regard his patients as individuals, Swiss psychiatrist Eugen Bleuler sought to understand his patients and coined the term schizophrenia.

The Name “Schizophrenia” Is Heard Worldwide

by Susannah Cahalan; New York: Grand Central Publishing, 2019

Graduate School of Medicine, University of Wollongong, Australia.

In 1973 the psychiatric profession was deeply shaken by a 

 that purported to show that psychiatric diagnosis was effectively useless.

 The author, Stanford psychologist David Rosenhan, described a unique experiment: Eight volunteer “pseudopatients” presented at psychiatric hospitals under fake names, complaining they heard voices. The intention was to examine psychiatric diagnosis: was it scientifically valid or merely a random, subjective, and erratic process?

The pseudopatients were in the hospital for a mean of 19 days. All but one were diagnosed with schizophrenia in remission. The statistics from the study showed contact with doctors averaged just 6.8 minutes a day; 71% of doctors averted their heads when addressed. While patients suspected study participants were fake-possibly because they spent their time writing notes-the staff did not.

Rosenhan’s message was devastating: “We cannot distinguish the sane from the insane in psychiatric hospitals,” adding, “If sanity and insanity exist, how shall we know them?” These findings, taken at face value, were very difficult to refute.

Pseudopatients and their discontents: an historical perspective

Arguably the most influential psychological paper published in the last half of the 20th century, it caused a sensation. By the 1980s, it was mentioned in most psychology textbooks. Rosenhan became a star in his field and the study still one of the most cited social science papers, as well as prescribed reading in psychology and social work courses.

A Conversation in Critical Psychiatry with Susannah Cahalan

The timing was good; the anti-psychiatry movement started in the 1960s by Szasz, Laing, Goffman, and others had kicked into high gear.

 played its part in persuading the counterculture to see psychiatry as inherently oppressive. Michael Foucault, the French intellectual superstar, said that asylums represented the punitive arm of society (based on his rather dubious historical research).

The response of psychiatrists to the paper was predictable. They rushed to defend their profession, although with varying degrees of conviction. It led to a vortex of discussion about the practice of psychiatry and its future. It fed into the deinstitionalization movement, an agenda driven by governments, radicals, the counterculture, and others. Although not realized at the time, the results were catastrophic. Community services could never come close to meeting the needs of the discharged patients and the vacuum was filled by the streets and prisons.

The fallout from the research played a part in the organizing principles that led to the 

Diagnostic & Statistical Manual (DSM-III) 

in 1980. For the first time, diagnoses were categorized with listed symptoms, free of etiological presumptions, notably psychoanalysis.

This brought with it an unexpected and unprecedented benefit. In a triumph of medical marketing, the American Psychiatric Association (APA) created a brand that may be as well-known as 

, culminating in its latest incarnation in 2013 with DSM-5. The APA made many millions and can expect the rivers of gold to keep flowing. But the solution was not megabucks alone. Has DSM solved the problems, not least epistemological, that beset psychiatric diagnoses? Hardly, if the furore of DSM-5 is any indication.

The paper did not lack supporters and news coverage. In Australia, an attempt was made to replicate it. Radical Sydney psychologist Dr Robin Winkler did two studies, published simultaneously in the 

 The first paper reported the findings of pseudopatients who had visited general practitioners claiming to suffer depression; in the second article the infiltrators had themselves admitted to psychiatric hospitals.

Winkler concluded that “a permanent body should be established with the co-operation of medical, research and consumer organisations, to report regularly on health care services as evaluated with pseudopatient observations.” Psychiatrist Neil McConaghy, who had a distinguished research record, was skeptical.

 While there could be some value in such studies, Winkler had failed to account for observer bias, if not other issues.

She first wrote of her psychiatric experience in 

, the account of how psychotic symptoms developed. She was seen by a number of psychiatrists and set to be admitted to a psychiatric hospital. A neurologist, however, discovered she had a rare autoimmune condition: anti-NMDA receptor encephalitis. She received treatment and recovered.

Anti-NMDA receptor encephalitis is extremely rare with 1.5 cases per million people (about 80% female) per year,

 and psychiatrists can hardly be blamed for not picking it up at the time. Cahalan, understandably, does not see this as an excuse and describes another undiagnosed case where the patient suffered brain damage.

The experience lingered; had she not had the neurological intervention, she would have suffered permanent brain damage. This did not dispose her favorably toward psychiatric science and led her to David Rosenhan. Rosenhan had died in 2012 but Cahalan was able to get access to his notes. Starting the journey in a spirit of optimism, she expected it to be a positive experience, but her hopes were soon dashed.

An early warning came from a colleague who called Rosenhan a “bullshitter.” Another, Eleanor Maccoby, was deeply suspicious saying it was “impossible to know what he had really done, or if he had done it,” according to Cahalan. The paper was his 

 and he lived off it for the rest of his career.

 One thing that puzzled Cahalan was his failure to complete a book on the study, commissioned with a lucrative advance payment which he had to return. The explanation for this was to come later as a denouement to the investigation.

It was known that Rosenhan was the first member of the pseudopatient group. Was it ethical or appropriate for the person running the study to participate in it? He was admitted as “David Lurie” to Haverford State Hospital in Pennsylvania. Cahalan found the notes of his interview with psychiatrist Frank Bartlett. He noted that Rosenhan had been suicidal, finding the voices so upsetting he put copper pots over his ears to tune them out and having symptoms for months. Rosenhan also said that he was sensitive to radio waves and could hear what people were thinking.

These are severe symptoms that every psychiatrist would take seriously. This is what Bartlett did; his admission notes conveyed a more detailed and disturbing picture of mental illness than Rosenhan said the pseudopatients had presented. Cahalan’s damning response: “Dr Bartlett wasn’t a bad doctor who made a bad decision . . . He was a good doctor who made the best call given the information he received.”

As her doubts escalated, she questioned whether the other pseudopatients even existed: “It was becoming alarmingly clear that the facts were distorted 

Cahalan tracked down Bill Underwood. Such was his emotional poise that Rosenhan questioned whether he could pass for a psychiatric patient, again showing the experimenter’s bias. As it happens, Underwood was admitted for 9 days with a diagnosis of paranoid schizophrenia. While Rosenhan stated that he carefully prepared his volunteers for the admissions, Underwood only recalled having brief guidance on how to hide pills in his cheek. The paper stated that Underwood had spent 7 days in a hospital with 8000 patients, but in fact he spent 8 days in a hospital with 1500 patients.

Harry Lando, pseudopatient No. 9, was cut from the study on the grounds that he “falsified aspects of his personal history.” He spent 19 days at an institution where the staff didn’t wear uniforms, he went to group therapy, and he had a beach day trip. Lando told Cahalan he was treated well and enjoyed the experience. This was not what Rosenhan wanted to hear. The notes state: “HE LIKES IT.” The result? Lando was excised from the study because his experience had been positive.

The identity of the other pseudopatients was a mystery, and Cahalan concluded that they were wholly fabricated, a finding that eliminates the likelihood there were just a few correctable mistakes in the study. In fact, another pseudopatient’s false details were inserted in his account. So much for including all study findings regardless of whether they supported the hypothesis.

Rosenhan could dismiss most objections by psychiatrists, but Robert Spitzer, as a leading figure behind DSM-III, was on a different level.

 Spitzer wrote, “Some foods taste delicious but leave a bad aftertaste.” The paper was “pseudoscience presented as science” and the conclusion a diagnosis of “logic in remission.” Rosenhan’s research methods were “unscientific”; the terms “sanity and insanity” were legal concepts, not psychiatric diagnoses; and the designation “in remission,” showed that the doctors were aware that the pseudopatients were different from the rest. Rosenhan failed to disclose his data and his sources, wilfully withholding information from readers.

These were penetrating and accurate criticisms which Cahalan followed in Rosenhan’s file. He became increasingly defensive as the exchange between the two progressed, enraged at being called out in this fashion. Cahalan put her finger on it: this was the reason he did not write the book commissioned on the study and had to pay back the lucrative advance fee. Rosenhan knew he was on thin the ice; being called out would be the end of his career.

One motivation for the experiment not considered was one of the oldest: turf war. Psychologists, especially at that time, were excluded from many activities on which psychiatrists had a “monopoly.” Discrediting their practice would expand the opportunities for psychologists and social workers.

Just as the paper was deeply damaging for psychiatry when it was published, it has now rebounded on psychology. Rosenhan’s effort, its deception unknown at the time, was the predecessor of the current replication crisis in psychology in which serious doubts have been raised about the work of Diederik Stapel, Philip Zimbardo, and Stanley Milgram.

Andrew Scull, hardly an admirer of psychiatry, 

 Rosenhan pulled off one of the greatest scientific frauds of the past 75 years, and its consequences still resonate today. One only has to look at the individuals crowding our streets and prisons, the result of deinstitutionalization, for which he should take much credit.

While some may react to the frequent insertions of her own experience, this is a minor criticism. Cahalan is to be congratulated on her meticulous investigation.

2. Laffey P. Histories of Psychiatry after Deinstitutionalisation: Australia and New Zealand. 

3. Owen A, Winkler RC. General practitioners and psychosocial problems: An evaluation using pseudopatients. 

4. Winkler RC. Research into Mental Health Practice Using Pseudopatients. 

5. McConaghy N. Pseudopatients and Evaluation of Medical Practice. 

6. Kayser MS,  Dalmau J. Anti-NMDA Receptor Encephalitis in Psychiatry. 

7. Guide to the David L. Rosenhan Papers. Online Archives of California. 

https://oac.cdlib.org/findaid/ark:/13030/c8tq6082/entire_text

8. Spitzer RL. On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan's “On being sane in insane places.” 

9. Scull A. How a fraudulent experiment set psychiatry back decades. The Spectator. January 25, 2020. 

https://www.spectator.co.uk/2020/01/how-david-rosenhans-fraudulent-thud-experiment-set-back-psychiatry-for-decades

Pseudopatients and their discontents: an historical perspective.

Author | Robert M. Kaplan, MBChB, MA (Journ), MPhil (Sc), FRANZCP

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