"The Great Pretender"

In 2009 journalist Susannah Cahalan was hospitalized for treatment of symptoms consistent with schizophrenia. A consulting neurologist was skeptical of the diagnosis, and upon further testing Cahalan was found to have an autoimmune disorder that attacked her brain. She was treated and her symptoms resolved. Her 2012 memoir, “Brain on Fire,” detailed her ordeal and its aftermath.

Cahalan’s experience prompted her to delve into the history of psychiatric diagnosis and misdiagnosis. The results of her research and the conclusions she drew are the subject of her most recent book “The Great Pretender.”

Early in her research Cahalan learned of a widely cited study that changed the course of psychiatric diagnosis and management. In 1973 Stanford University professor of psychology David Rosenhan published a paper in the journal Science that upset much of then current thinking about psychiatric diagnosis and treatment.

The study, titled “On Being Sane in Insane Places,” was based on data derived from the hospitalization of eight healthy individuals, including Rosenhan himself. These “pseudopatients” had been coached how to respond to psychiatric interview questions in such a way that they would be diagnosed with a mental disorder sufficient to prompt their admission to psychiatric hospitals.

After admission to these highly regarded institutions they were required to prove their “sanity” to gain their release. Rosenhan’s conclusion was that psychiatric diagnostic techniques were incapable of differentiating between those who were truly mentally ill and those who were not.

The study hit the psychiatric community like a well-aimed SCUD missile. Received amid great controversy, the study prompted widespread modifications in diagnosis and treatment of mental illness. These changes included the development of strict, evidence-based criteria for psychiatric diagnosis. As a further consequence a large number of psychiatric hospitals closed nationwide.

There was only one problem: Cahalan discovered that some, and perhaps most of the data supporting the article was false. Rosenhan had suffered a series of debilitating strokes in the early 2000s and died in a care facility a decade later, so he was not available for interview. Cahalan had, however, been able to gain access to the bulk of Rosenhan’s papers, including the manuscript of an unpublished book. As she dug deep into this material she encountered discrepancies, contradictions, and in increasing numbers material that appeared to be outright fabrication.

But Rosenhan’s study continues to be one of the mostly widely cited papers in the discipline of social science. Cahalan concludes, “In the end I believe that he exposed something real. Rosenhan’s paper, as exaggerated, and even dishonest, as it was, touched on truth as it danced around it—the role of context in medicine; the dismissal of psychiatric conditions as less legitimate than physical ones; the depersonalization felt by mentally ill ‘other;’ the limitations of our diagnostic language. The messages were worthy; unfortunately the messenger was not.”

Readers will find “The Great Pretender” engaging on several levels. For those who have an interest in mental health the details of the development of current diagnostic tools will prove fascinating. Those who enjoy watching a journalistic discovery unfold will find it difficult to put down. And the author’s breezy prose style will hold the interest of readers from start to finish.