It all started with a talk on malingering.

Malingering is defined as the conscious fabrication or exaggeration of physical or psychological symptoms for secondary gain. Examples are useful here:

• Ferris Bueller. (”Anyone? Anyone?”) He feigns a feverish cold (symptoms) so he can enjoy the day (secondary gain) with Cameron (hot!) and Sloane.
• A soldier reports significant abdominal pain (though he had none) and other related symptoms to decrease the likelihood that he will deployed to fight in a war.
• A man without any psychological problems who murdered a family reports to his lawyer that tormenting hallucinations and delusions coerced him to complete this deed—that he is not responsible for his actions.

How skilled are psychiatrists at detecting psychological malingering?

Not very. There aren’t a lot of studies on this topic, though the reports that are available suggest that psychiatrists, at best, miss malingering in over 10% of people who present with feigned symptoms. (The usual statistic hangs out closer to 50%. I don’t remember the citation and I currently can’t find it on Pubmed.)

Certainly context matters. The psychiatrists who work in emergency rooms have many more tales of people who malinger than private practice psychoanalysts in hoity-toity parts of town. Most agree, however, that while we should remain vigilant for malingering, it doesn’t happen that often. (Still, no one is entirely sure what that means.)

One paper that is frequently cited in the malingering literature is this fantastic article, which actually isn’t really about malingering:

On being sane in insane places. (Very long, unformatted paragraph follows.)

It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meanings of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment-the powerlessness, depersonalization, segregation, mortification, and self-labeling-seem undoubtedly countertherapeutic. I do not, even now, understand this problem well enough to perceive solutions. But two matters seem to have some promise. The first concerns the proliferation of community mental health facilities, of crisis intervention centers, of the human potential movement, and of behavior therapies that, for all of their own problems, tend to avoid psychiatric labels, to focus on specific problems and behaviors, and to retain the individual in a relatively non-pejorative environment. Clearly, to the extent that we refrain from sending the distressed to insane places, our impressions of them are less likely to be distorted. (The risk of distorted perceptions, it seems to me, is always present, since we are much more sensitive to an individual’s behaviors and verbalizations than we are to the subtle contextual stimuli that often promote them. At issue here is a matter of magnitude. And, as I have shown, the magnitude of distortion is exceedingly high in the extreme context that is a psychiatric hospital.) The second matter that might prove promising speaks to the need to increase the sensitivity of mental health workers and researchers to the Catch 22 position of psychiatric patients. Simply reading materials in this area will be of help to some such workers and researchers. For others, directly experiencing the impact of psychiatric hospitalization will be of enormous use. Clearly, further research into the social psychology of such total institutions will both facilitate treatment and deepen understanding. I and the other pseudopatients in the psychiatric setting had distinctly negative reactions. We do not pretend to describe the subjective experiences of true patients. Theirs may be different from ours, particularly with the passage of time and the necessary process of adaptation to one’s environment. But we can and do speak to the relatively more objective indices of treatment within the hospital. It could be a mistake, and a very unfortunate one, to consider that what happened to us derived from malice or stupidity on the part of the staff. Quite the contrary, our overwhelming impression of them was of people who really cared, who were committed and who were uncommonly intelligent. Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves than to personal callousness. Their perceptions and behavior were controlled by the situation, rather than being motivated by a malicious disposition. In a more benign environment, one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective.

It’s not a hard-hitting scientific paper in that it does not have robust study methods, etc. Though published in 1973 (prior to two revisions of the DSM), it still has relevance today and, at eight pages long, it is an easy, thoughtful, and humbling read. (For those of you with institutional access, you can find it within the online Science archives; for those of you who do not, simply consult the oracle—the full text is out there. Alternatively, you can read the summary on Wikipedia, though it does not do the original article justice.)

Much of the paper deals with the issue of context: What are the consequences of labels? environments? How do interpretations of behaviors change as a result of the current circumstances? At the time the paper was published, cognitive-behavioral psychological theory was experiencing greater dissemination, but psychodynamic/psychoanalytic psychiatry was still the primary mode of diagnosis and treatment. Psychodynamic theory does not emphasize environmental context (i.e. thoughts and behaviors are attributed chiefly to intrapsychic phenomena). This paper clearly criticizes this perspective (amongst other things). (Compare this with Gladwell’s The Tipping Point. Gladwell spends much of the book discussing “The Power of Context”—he argues that the crime rate in New York City declined in the 1990s because the environment—graffiti-free subway cars, the absence of broken windows, etc.—did not encourage misdemeanors. No one is going to tag a building if it is well-lit, clean, and sparkly.)

We interact with each other and the environment in a dynamic way. Does our individualist culture facilitate beliefs that we are more independent than we really are?

While on the subject of psychiatric misdiagnosis, I looked further into the “Martha Mitchell Effect“. (Hi Brock!) There is only one article in the literature that discusses this phenomena:

Robitscher, Jonas. “Stigmatization and stonewalling: The ordeal of Martha Mitchell.” Journal of Psychohistory. 1979. Vol. 6, Iss. 3; p. 393-408.

In a 1977 TV interview with David Frost, former President Richard Nixon suggested that Martha Mitchell’s mental and emotional problems had so upset her husband John, then the attorney general, that he was unable “to mind the store” and thus allowed Watergate to occur. The present paper finds that the facts were quite different, that there is no evidence that Martha Mitchell was mentally ill, and that there is evidence that she was labeled by those involved in the Watergate conspiracy so that her suspicions would be discounted. The story of Martha Mitchell’s mistreatment is described in detail as an example of political stigmatizing. It is suggested that Nixon’s confusion was based on projection: Martha, rather than John or Richard, was responsible for Watergate.

It’s a slippery slope, yeah? I’m hoping to get my hands on a copy of the article; it sounds fascinating. In fact, the Journal of Psychohistory sounds intriguing—though potentially too psychoanalytic for my tastes. (Just to be clear: I am not totally anti-psychoanalytic psychiatry; I just can’t grasp the concepts with the same ease that I comprehend cognitive-behavioral theory. I’m concrete that way.)

And notice where the Journal of Psychohistory is published? That’s right, New York City. Wouldn’t it be awesome if I lived in New York City next year? Wouldn’t it? WOULDN’T IT?