7.3 Schizophrenia-as-Role-Play

A third way that social problems can be mistaken for mental illness is when patterns of schizophrenic thought and behaviour are simulated. This can happen when the schizophrenic role is either deliberately chosen by the schizophrenic, or imposed by other people. Analysts who argue that such roles are normally chosen by the schizophrenics themselves are inclined to see schizophrenics as predatory, exploitative types of people.[37] Conversely, those who prefer to see the schizophrenic role as an imposition tend to argue that schizophrenics are victims of labelling who, once diagnosed, are compelled by other people’s expectations to behave in the prescribed manner of a schizophrenic.[38]

The evolution of Thomas Szasz’s myth-of-mental-illness views has involved a passage through both the schizophrenic-as-cultural-outsider and the schizophrenic-as-scapegoat types. But more recently his attachment to libertarian philosophy has swung him into the schizophrenia-as-role-play model. He shows a distinct lack of sympathy for people who willingly adopt the role of schizophrenic. In a recent article, descriptively entitled Idleness and Lawlessness in the Therapeutic State, he refers to schizophrenics as parasites. After establishing that modern society is divided between producers and parasites he goes on to argue that people with ‘real’ illnesses who adopt the sick role are not idle and therefore not parasites. However, ‘in contrast, most chronic mental patients—especially schizophrenics—are idle, economically dependent, and inclined (allegedly because of their illness) to lawlessness’.[39]

Szasz’s view is that failure to make the necessary transitions in the process of maturation—from childhood to adolescence to adulthood—is what determines whether a person will become identified as a schizophrenic. If a person successfully passes through the first two stages and establishes an adult identity by ‘being useful to other people’[40]—that is, by having a productive occupation—the society will accept the person as being in mental health.

But ‘[i]f this process of maturation goes awry, the adolescent begins to envy his peers and to feel inferior to them’.[41] When this happens, in order to compensate, the person might intentionally develop notions of self-importance and perhaps begin to express unusual beliefs and mannerisms, as marks of assumed distinguishment. According to Szasz, as such a person slides further away from a normal productive adult identity, family members, teachers and friends tend to indulge the person and offer more leeway. The process of differentiation continues until the person gives some suggestion of potential violence. At this point the person is likely to be brought into contact with a psychiatrist who will give a diagnosis of schizophrenia. Henceforth the well-known symptoms of schizophrenia provide an easily followed identity-script to guide the person in his or her future career as a schizophrenic.

The assumption is that a person with parasitic tendencies will sometimes simulate schizophrenic symptoms as a way to gain access to the perquisites of mental patient-hood. These supposed perks include additional family attention, social welfare payments and the right to be idle. This perception of exploitation is now so widespread that Szasz's 'myth of mental illness' arguments have even been raised by US policy analysts concerned about the growing welfare burden on taxpayers.[42]

Szasz’s point of view is also shared by a significant proportion of the business community. Recent research has found that one-third of middle and senior level business managers in Sydney and Melbourne believe that ‘mental illnesses such as schizophrenia and manic depression are myths dreamed up by lazy workers’ as excuses 'used to escape work or gain personal rewards’.[43]

The simulation of madness for personal advantage or disguise is not a new idea. It must have been well understood in late-sixteenth-century England, for instance, because in a number of Shakespeare’s plays characters feign madness in order to disguise either their identities or their intentions. Hamlet feigns madness to put his enemies off guard. In King Lear, Edgar adopts the persona of the madman, Poor Tom. When he fears for his life he flees into the countryside. But before he goes he tells the audience about the disguise he will adopt, to avoid detection—and also to help him earn a living.

My face I’ll grime with filth,
Blanket my loins, elf all my hair in knots,
And with the presented nakedness outface
The winds and persecutions of the sky.
The country gives me proof and precedent
Of Bedlam beggars, who with roaring voices,
Strike in their numb’d and mortified bare arms
Pins, wooden pricks, nails, sprigs of rosemary;
And with this horrible object, from low farms,
Poor pelting villages, sheep-cotes, and mills,
Sometime with lunatic bans, sometime with prayers,
Enforce their charity. Poor Turlygood! poor Tom!

That’s something yet: Edgar I nothing am.[44]

Curiously, DSM-IV now has a diagnostic label for people who fabricate madness in the way that Edgar does. In fact there are two different disorders to choose between. If Edgar were detected in the act of feigning madness by a modern psychiatrist he might be diagnosed with Malingering—but only if the diagnostician thought that ‘enforcement of charity’ was Edgar’s motivation. Malingering is used to describe a person who is perceived to intentionally produce false or exaggerated psychological or physical symptoms because he or she is ‘motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs’.[45]

The alternative diagnosis for feigners of madness is Factitious Disorder—With Predominantly Psychological Signs and Symptoms. This label is used when there is the same intentional feigning ‘of psychological (often psychotic) symptoms that are suggestive of a mental disorder’ and ‘the motivation for the behaviour is to assume the sick role’.[46] But unlike Malingering, people with Factitious Disorder are not motivated by external incentives such as economic gain. Factitious Disorder is also known as Munchausen Syndrome.[47]

The existence of these disease categories in DSM-IV confirms the claim that schizophrenia can be simulated, and is therefore sometimes a psychiatric myth. But it also reveals a somewhat bizarre divergence of opinion between medical psychiatry and the psychiatric myth school. What DSM-IV is claiming is that mentally healthy people who pretend to be mentally ill are, by virtue of their pretence,  mentally ill. Psychiatrists believe that the pretence is itself a form of mental illness. This sort of twisted logic offers a free-kick to the myth of mental illness sceptics.

The paradoxical situation that arises from the medicalisation of play-acting is further compounded by the inclusion of a variant of Factitious Disorder, called Factitious Disorder By Proxy (FDBP), in an appendix of DSM-IV.[48] FDBP is one of a number of mental disorders that are already recognised by large sections of the psychiatric profession but which have yet to achieve consensual endorsement. In DSM-IV’s Appendix B, descriptions are given of these disorders and further research into them is recommended.

The essential feature of FDBP

is the deliberate production of physical or psychological signs or symptoms in another person who is under the individual’s care … The motivation for the perpetrator’s behaviour is presumed to be a psychological need to assume the sick role by proxy … The perpetrator induces or simulates the illness or disease process in the victim and then presents the victim for medical care while disclaiming any knowledge of the actual etiology of the problem.[49]

To a psychiatric sceptic FDBP might appear at first glance to provide the simplest of all explanations for the cause of schizophrenia. That is, schizophrenic symptoms are fabricated by relatives and psychiatrists who are suffering from FDBP, and who are adopting the sick role by proxy. However, FDBP presents sceptics of the myth of mental illness school with a conundrum: if all mental illness is a myth, then so is FDBP.

But even if Malingering and the Factitious Disorders present problems of usage by the psychiatric myth school their inclusion in DSM-IV confirms that mainstream psychiatry recognises that  schizophrenia is sometimes only role-playing. The problem is that nobody seems to know how many schizophrenics are either role-playing themselves, or are the victims of role-playing by relatives and psychiatrists.

Tests have shown fairly conclusively that people without a diagnosis of schizophrenia can fabricate the symptoms on request so well that psychiatrists are willing to diagnose them with schizophrenia. The authors of one of these studies concluded that all that is required for normal people to successfully simulate schizophrenia is that they have some prior knowledge of the symptoms.[50] Another survey found that when normal people were coached in the methods of detecting schizophrenic simulation a third of them could feign schizophrenia without detection.[51]

However, an accurate knowledge of either the symptoms of schizophrenia, or methods for detecting simulators, might not be necessary for pretenders in real-life situations outside the laboratory. The much-cited Rosenhan experiment[52] found that a high level of accuracy is not required in the simulation of symptoms, and that practising mental health professionals are unlikely to expose pretenders.

In an experiment conducted in the early 1970s, Rosenhan enlisted eight volunteers to act as pseudo-patients. Over a period of time the pseudo-patients presented themselves at twelve psychiatric hospitals and complained of hearing voices saying the words ‘empty’, ‘hollow’ and ‘thud’. These words had been chosen because of their existential connotations suggesting the emptiness of life and because they had never appeared in psychiatric literature as being symptoms of mental illness.

No other symptoms were fabricated, and on each occasion the pseudo-patients were admitted to the hospitals, and on all but one occasion they were diagnosed as having schizophrenia. After the initial interview the volunteers did not mention the voices again and acted their normal sane selves. The agreement they had made with the co-ordinator of the experiment was that they would each have to gain their own release without any outside assistance. This had to be done by convincing the hospital staff they were sane. The length of hospitalisation ranged from seven to 52 days, with an average of nineteen days. All those originally diagnosed as having schizophrenia were released with the diagnosis of ‘schizophrenia in remission’. One conclusion made by the co-ordinator of the experiment was that, ‘[p]sychiatric diagnoses … are in the minds of the observers and are not valid summaries of the characteristics displayed by the observed’.[53] Rosenhan’s principal contention was that mental hospitals could not tell the sane from the insane.

Rosenhan was a psychologist, and when his study was first published in the journal Science there was widespread protest from members of the psychiatric profession. The next issue of the journal had fifteen letters in response, only one of which was favourable. A symposium discussing his experiment was subsequently published in the Journal of Abnormal Psychology. All of the five psychologists who contributed articles were critical of Rosenhan.[54] Most of the criticism was concerned with either the ethics of the experiment or the methodology. The ethical problems mostly focussed on the deliberate intention of deceiving hospital staff which was inherent in the design of the experiment. Only one commentator, Thomas Scheff, writing at a later date, seems to have raised a further ethical question concerning the considerable risks that were taken by the pseudo-patients in subjecting themselves to an average nineteen days of incarceration and psychiatric treatments.[55]

One of the major criticisms about Rosenhan’s methodology was the lack of controls. It was argued by one of the contributors to the symposium that the experiment was of little value because no controls had been used. It was proposed that if there had been a control group which was unaware of the purpose of the experiment, then the members of this control group might have tried a lot harder to get out of hospital than did Rosenhan’s pseudo-patients.[56]

Despite these criticisms, Rosenhan’s findings still had a considerable impact on the psychiatric profession in the United States by temporarily undermining confidence in the validity of psychiatric diagnoses. Kirk and Kutchins relate how Rosenhan’s work particularly affected Robert Spitzer, who was one of the principal architects of the DSM revision that became DSM-III: ‘He obviously took Rosenhan’s work very seriously; it constituted a frontal assault on psychiatric diagnosis.’[57]

Spitzer challenged Rosenhan in an article entitled ‘On pseudoscience in science, logic in remission, and psychiatric diagnosis: a critique of Rosenhan’s “On being sane in insane places”’. In this article, Spitzer offered the simplistic argument that, ‘A correct interpretation of [Rosenhan’s] own data contradicts his own conclusions. In the setting of a psychiatric hospital psychiatrists are remarkably able to distinguish the “sane” from the “insane”‘. Spitzer argued that being released from hospital with ‘schizophrenia in remission’ was tantamount to being found sane.[58]

Although Spitzer claimed a successful refutation, Rosenhan’s study is still ‘often discussed in introductory college courses in psychology and sociology’[59] to illustrate problems with psychiatric diagnosis. It has also recently been recommended in legal literature for use as a courtroom reference to refute the certainty of psychiatric assessments: ‘Plaintiffs’ experts should be asked to admit that psychiatrists can be fooled and that malingering is difficult to detect. In this connection, defence counsel should use the famous Rosenhan study‘.[60] Despite the many criticisms, Rosenhan’s experiment has survived as a landmark demonstration of how easy it is to simulate symptoms that lead to a diagnosis of schizophrenia.

Another elaborate experiment has demonstrated the converse of Rosenhan’s findings. That is, in order to comply with falsely conceived professional standards, psychiatric and psychological diagnosticians sometimes imagine the symptoms of mental illness in people who are behaving normally. Maurice Temerlin of the University of Okalahoma demonstrated this when he presented a man in perfect mental health for diagnosis by various groups of psychiatrists, psychologists and psychology students. Before these diagnosticians were allowed to observe the man, they were supplied with a fabricated suggestion by an expert in the field that the man was mentally disordered.[61]

To set up his experiment Temerlin had a professional actor trained to portray a mentally healthy man using the following criteria:

he was happy and effective in his work; he established a warm, gracious and satisfying relationship with the interviewer; he was self-confident and secure, but without being arrogant, competitive, or grandiose. He was identified with the parent of the same sex, was happily married and in love with his wife, and consistently enjoyed sexual intercourse. He felt that sex was fun, unrelated to anxiety, social-role conflict, or status striving. This was built into his role because mental patients allegedly are sexually anhedonic.[62]

The actor’s role also required him to be agnostic and uninterested in extrasensory perception or occult phenomena. This was to avoid subjects often associated with schizophrenia. He also had a gentle self-mocking sense of humour to combat the normal perception that mental patients are humourless people who have no insight into themselves. The actor’s script required him to deny that he had ever experienced hallucinations, delusions or any other phenomena associated with psychosis.

To cap it off, a happy childhood was created for him together with mild anxieties about current political affairs, to demonstrate social concern and the absence of self-obsession. His domestic life was happy and only punctuated by occasional disagreements with his wife about church-going, and infrequent musings about whether he was raising his children correctly.

The experiment required a recording to be made of Temerlin interviewing the actor as if he were a prospective patient. In order to account for the clinical setting, so that sickness would not automatically be assumed by the audience, the script described the actor as ‘a successful and productive physical scientist and mathematician (a profession as far away from psychiatry as possible) who had read a book on psychotherapy and wanted to talk about it’.[63]

The actor himself was not told the purpose of the experiment. After the recording was made, three clinical psychologists evaluated the interview to ensure that the actor had indeed portrayed a man in perfect mental health. Temerlin then recruited twenty-five practising psychologists, twenty-five psychiatrists and forty-five graduate students enrolled in doctoral programmes in clinical psychology.

The purpose of the experiment was to test whether diagnosticians could be influenced in their clinical judgement by a false statement given by a ‘prestige confederate’. Before the psychologists and psychology students heard the interview, they were told by a well-known psychologist who had gained many professional honours that the patient on the taped interview they were about to listen to was ‘a very interesting man because he looks neurotic, but actually is quite psychotic’. Similarly, the twenty-five psychiatrists were told that ‘two board-certified psychiatrists, one also a psychoanalyst, had found the recording interesting because the patient looked neurotic but actually was quite psychotic’.[64]

Control groups were also tested. One control group was asked to diagnose the actor without any prior prestige suggestion at all. Another group made diagnoses after hearing a prestige suggestion that the actor was mentally healthy. The results were quite extraordinary. As can be seen in the following table the psychiatrists were particularly vulnerable to being misled by the ‘prestige suggestion’.

 Diagnoses with Suggestion of Psychosis
  Psychosis Neurosis Mental Health
 Psychiatrists (25)15
 10 0
 Clinical Psychologists (25) 7 15 3
 Psychology Students (45) 5 35 5

 Control Groups
  Psychosis Neurosis Mental Health
 No prestige suggestion (21)0
 Suggestion of mental health (20) 00

Adapted from: Maurice K. Temerlin, ‘Suggestion Effects in Psychiatric Diagnosis’, in Thomas J. Scheff, Labelling Madness, Prentice-Hall, Englewood Cliffs N.J., 1975, p. 50.

Schizophrenia was the most common form of psychosis diagnosed, and the results in many ways speak for themselves. After analysing the data Temerlin concluded that professional identity was the relevant variable and that there was no relationship in diagnostic outcomes with either length of training or experience. What is apparent is that the psychiatrists in particular were inclined to adopt a professional role-play after the appropriate script was supplied to them by a prestige confederate whose opinion could be assumed to represent professional standards.

In attempting to explain why the psychiatrists were more easily led into diagnosing a healthy person as psychotic, Temerlin observed that: ‘Psychiatrists are, first and foremost, physicians. It is characteristic of physicians in diagnostically uncertain situations to follow the implicit rule “when in doubt, diagnose illness”, because it is a less dangerous error than diagnosing health when illness is in fact present.’ This point was punctuated by a statement from one psychiatrist who, after learning about his error, defended a diagnosis of psychosis by arguing: ‘Of course he looked healthy, but hell, most people are a little neurotic, and who can accept appearance at face value anyway?’[65]

There is scope to speculate about the role of patient fees in this apparent willingness by psychiatrists to diagnose mental illness in healthy people. DSM-IV identifies Malingering as a diagnosis for use when patients fabricate symptoms for personal gain. But, unlike Factitious Disorder, the manual does not supply a proxy complement of Malingering which could be used when mental health professionals fabricate symptoms for their personal gain. It is not surprising that Malingering By Proxy fails to even make it into Appendix B, as an area recommended for further research. But this omission leaves the way open for cynics to argue that the compilers of DSM-IV might have insufficient insight into the real cause of at least some cases of supposed schizophrenia.

There is little likelihood a method can be developed that will eliminate role-playing as a factor in schizophrenia. Most mental diseases share the same conceptual weakness of not having laboratory tests to confirm diagnoses. With schizophrenia this problem is compounded. As presently conceived, schizophrenia is a condition in which the mind plays tricks on itself. This means that once a person is diagnosed, and becomes known as a 'schizophrenic', psychiatrists and relatives expect the person to make improbable claims about mental functions. An attempted confession of role-playing, or a claim to have been a victim of other peoples' role-playing, simply provides evidence that a person lacks insight into their diseased mental state. This means that once a diagnosis has been given on the basis of role-playing it is unlikely to be overturned. As Rosenhan's pseudo-patients found, a verdict of 'schizophrenia in remission' is the best that can be expected.

A notable exception is the New Zealand writer, Janet Frame. Frame has given a detailed account in her autobiography of how she came to be diagnosed with schizophrenia and incarcerated in the back ward of a mental hospital. It seems that as a painfully shy young woman she became infatuated with a former psychology lecturer who had taken a interest in what he called her 'loneliness of the inner soul'.

To attract, and maintain, the attention of the young psychologist Frame simulated the symptoms of schizophrenia:

I built up a formidable schizophrenic repertoire: I'd lie on the couch while the young handsome John Forrest, glistening with newly-applied Freud, took note of what I said and did, and suddenly I'd put on a glazed look in my eye, as if I were in a dream, and begin to relate a fantasy as if I experienced it as a reality. I'd describe it in detail while John Forrest listened, impressed, serious. Usually I incorporated in the fantasy details of my reading on schizophrenia.[66]

The unexpected penalty for this 'game, half in earnest, to win the attention of a likeable young man',[67] was involuntary commitment for eight years in an infamous mental hospital. Here she received more than two-hundred electroshock treatments and was on a short list for psychosurgery when a book she had written many years before unexpectedly won a major literary prize. This amazing stroke of good fortune allowed a new hospital psychiatrist to accept 'me as I appeared to him and not as he learned about me from my, "history" or reports of me'.[68] As a result she was rapidly rehabilitated and released. But her subsequent confession of role-playing as being the original cause of her troubles is probably only credible because she is now regarded as New Zealand's best-known living author. Without a prominent post-schizophrenia career to demonstrate sanity it is unlikely that her version of events would be believable.

[37] Thomas Szasz, ‘Psychiatric diagnosis, psychiatric power and psychiatric abuse’, pp. 135–8,

[38] Thomas Scheff, ‘Schizophrenia as Ideology’, in Scheff, ed., Labelling Madness, pp. 5–12.

[39] Thomas Szasz, ‘Idleness and Lawlessness in the Therapeutic State’, p. 30–6.

[40] Ibid.

[41] Ibid.

[42] Phillip D. Arben, ‘Are Mental Illnesses Biological Diseases? Some Public Policy Implications’, pp. 66–70.

[43] Robert Spillane, professor in Management, Macquarie University, Sydney, reported in ‘Mental illness myth: bosses’, Sunday Telegraph (Sydney), 19 September 1999.

[44] William Shakespeare, King Lear, Act II, Scene III.

[45] American Psychiatric Association, op. cit., p. 683.

[46] Ibid., pp. 472, 474.

[47] John B. Murray, ‘Munchausen Syndrome/Munchausen Syndrome by Proxy’, pp. 343–53.

[48] American Psychiatric Association, op. cit., pp. 725–7.

[49] Ibid., p. 725.

[50] B. E. Netter and D. J. Viglione Jr, ‘An empirical study of malingering schizophrenia on the Rorschach’, pp. 45–57.

[51] R. Rogers et al., ‘Feigning Schizophrenic Disorders on the MMPI-2: Detection of Coached Simulators, pp. 215–26.

[52] David L. Rosenhan, ‘On being Sane in Insane Places’, pp. 250–58.

[53] Ibid, p. 251.

[54] Thomas J. Scheff, Being Mentally Ill, Aldine, New York, 1984, p. 190.

[55] Ibid.

[56] T. Millon, ‘Reflections on Rosenhan’s On being sane in insane places’, pp. 456–61.

[57] Stuart A. Kirk and Herb Kutchins, The Selling of DSM: the rhetoric of science in psychiatry, pp. 90–7.

[58] R. L. Spitzer, ‘On pseudoscience in science, logic in remission, and psychiatric diagnosis: a critique of Rosenhan’s “On being sane in insane places”, pp. 442–52.

[59] Kirk and Kutchins, op. cit., p. 93.

[60] James T. Brown, ‘Compensation neurosis rides again: a practitioner’s guide to defending PTSD claims (post traumatic stress disorder)’, pp. 467–82.

[61] Maurice K. Temerlin, ‘Suggestion Effects in Psychiatric Diagnosis’, pp. 46–54.

[62] Ibid., p. 47.

[63] Ibid., pp. 47–8.

[64] Ibid., p. 48.

[65] Ibid., p. 52.

[66] Janet Frame, An Angel at My Table, Vintage, Auckland, 1984, p. 78.

[67] Ibid., p. 79.

[68] Ibid., p. 108.