Thud

In 1972, a psychologist named David Rosenhan convinced some of his friends to fake their way into psychiatric wards across the US.

The pseudopatients were to present themselves and say words along these lines: "I am hearing a voice. It is saying thud." Rosenhan specifically chose this complaint because nowhere in psychiatric literature are there any reports of any person hearing a voice that contains such obvious cartoon angst.

yes but this just isn't something from the 1970s.. oh no, my feelings of loathing for much of the mental health profession goes deeper

I don't feel in control, though. At any moment someone might recognise my gig. As soon as I say, "Thud", any well-read psychiatrist could say, "You're a trickster. I know the experiment." I pray the psychiatrists are not well-read.

I am brought to a small room that has a stretcher with black straps attached to it. "Sit," the ER nurse tells me, and then in walks a man, closing the door behind him - click click.

"I'm hearing a voice," I say.

He writes that down on his intake sheet, nods knowingly. "And the voice is saying?"

"Thud."

The knowing nod stops. "Thud?" he says. This, after all, is not what psychotic voices usually report. They usually send ominous messages about stars and snakes and tiny hidden microphones.

"Thud," I repeat.

"Is that it ?" he says.

"That's it," I say.

"Did the voice start slowly, or did it just come on?"

"Out of the blue," I say, and I picture, for some reason, a plane falling out of the blue, its nose diving downward, someone screaming. I am starting, actually, to feel a little crazy. How hard it is to separate role from reality, a phenomenon social psychologists have long pointed out to us.

"So when did the voice come on?" Mr Graver asks.

"Three weeks ago," I say, just as Rosenhan and his confederates reported.

He asks me whether I am eating and sleeping OK, whether there have been any precipitating life stressors, whether I have a history of trauma. I answer a definitive no to all of these things: my appetite is good, sleep normal, my work proceeds as usual.

"Are you sure?" he says.

"Well," I say, "as far as the trauma goes, I guess when I was in the third grade, a neighbour named Mr Blauer fell into his pool and died. I didn't see it, but it was sort of traumatic to hear about."

Mr Graver chews on his pen. He's thinking hard.

"Thud," Mr Graver says. "Your neighbour went thud into his pool. You're hearing 'thud'. We might be looking at post-traumatic stress disorder. The hallucination could be your memory trying to process the trauma."

"But it really wasn't a big deal," I say. "It was just ..."

"I would say," he says, and his voice is gaining confidence now, "that having a neighbour drown constitutes a traumatic loss. I'm going to get the psychiatrist to evaluate you, but I really suspect that we're looking at post-traumatic stress disorder with a rule out of organic brain damage, but the brain damage is way far down the line. I wouldn't worry about that."

He disappears. He is going to get the psychiatrist. The psychiatrist enters the little locked room. The psychiatrist looks sad, and baffled, and then says, "But the voice is bothering you."

"Sort of, yeah."

"I'm going to give you an antipsychotic," he says, and as soon as he says this the sadness goes away. His voice assumes an authoritative tone; there is something he can do. "I'm going to give you Risperdal," he says. "That should quiet the auditory centres in your brain."

"So you think I'm psychotic?" I ask.

"I think you have a touch of psychosis," he says, but I get the feeling he has to say this, now that he's prescribing Risperdal. It becomes fairly clear to me that medication drives the decisions, and not the other way around. In Rosenhan's day, it was pre-existing psychoanalytic schema that determined what was wrong; in our days, it's the pre-existing pharmacological schema, the pill. Either way, Rosenhan's point that diagnosis does not reside in the person seems to stand.

"But do I appear psychotic?" I ask.

He looks at me. He looks for a long, long time. "A little," he finally says.

"You're kidding me," I say, reaching up to adjust my hat.

"You look," he says, "a little psychotic and quite depressed. And depression can have psychotic features, so I'm going to prescribe you an antidepressant as well."

Was this a freak accident? Surely most doctors do not prescribe antipsychotics and antidepressants at the drop of a hat? Or do they?

It's a little fun, going into ERs and playing this game, so over the next eight days I do it eight more times, nearly the number of admissions Rosenhan arranged.

Each time, I am denied admission, but, strangely enough, most times I am given a diagnosis of depression with psychotic features, even though, I am now sure, after a thorough self-inventory and the solicited opinions of my friends and my physician brother, I am really not depressed. (As an aside, but an important one, a psychotic depression is never mild; in the DSM, it is listed in the severe category, accompanied by gross and unmistakable motor and intellectual impairments.)

I am prescribed a total of 25 antipsychotics and 60 antidepressants. At no point does an interview last longer than 12 and a half minutes, although at most places I needed to wait an average of two and a half hours in the waiting room. No one ever asks me, beyond a cursory religious-orientation question, about my cultural background; no one asks me if the voice is of the same gender as I; no one gives me a full mental status exam, which includes more detailed and easily administered tests to indicate the gross disorganisation of thinking that almost always accompanies psychosis. Everyone, however, takes my pulse.

read the whole thing