What ruined your insanity

Margret O. knew that she was mentally ill. After all, she is a psychiatrist herself. The doctor had already treated dozens of manic patients. But when she herself went to a clinic during a manic episode, her view of her own profession changed drastically.

"How the doctors reacted when I refused to take any medication was a key experience," she recalls. If she didn't take the drug willingly, nurses would strap her to a bed and force her down on the pills. "Up to this threat I was more or less under control, but then I got angry," remembers Margret O.

Violence as a means of pressure

Violence is still one of the means of pressure used in psychiatry today. Patients with depression, panic attacks or schizophrenia do not always come to a clinic voluntarily; many are admitted under pressure from their families or by the police.

624,000 people were treated in German mental hospitals in 2003, not counting the 370,000 admissions for alcohol and other drugs.

Most patients follow the advice of doctors and are discharged stably after days or weeks. Those who do not submit can easily get into a vicious circle: Neurologists are often so convinced of the correctness of their diagnosis that they see a patient's resistance as proof of his mental illness.

The problem: Usually the doctors are right. But not always. Sometimes a patient has every reason to fight back because the diagnosis is wrong. "Misdiagnoses are a common phenomenon in psychiatry," says psychologist Hans-Ulrich Wittchen from the TU Dresden. "They are likely to be much more frequent than in other subjects."

While surgeons, internists and general practitioners have recently been establishing error reporting systems, such initiatives are lacking in psychiatry. When asked how often doctors and psychologists are wrong when assessing a person's soul, no expert can give an answer.

The result is that spectacular cases shape the perception. Cases in which misdiagnosis has ruined a life - like Vera Stein's. The 45-year-old was admitted by her father in 1974 at the age of fourteen.

For six years she was held in clinics as "schizophrenic" and sedated with medication. It was not until 1980 that it became clear that Vera Stein was healthy. Only last June, the European Court of Human Rights sentenced Germany to compensation of 75,000 euros.

The Federal Association of Experienced Psychiatrists knows numerous people with similar experiences. Their common reproach: every day, healthy people are stigmatized as mentally ill due to superficial and incorrect diagnoses, put down in a clinic and deprived of their rights.

Does this assessment correspond to reality or does a small group of those affected paint an all too gloomy picture here? It is "rare," says Wolfgang Maier, a psychiatrist at the University of Bonn, that healthy people are unjustifiably declared mentally ill: "The more common problem is the opposite."

Mental illnesses are often overlooked - this is particularly true of the mass illness depression. The schizophrenia specialist Wolfgang Gaebel also sees this shortcoming. "But both errors - too much and too little in the diagnosis - are by no means mutually exclusive," said the psychiatrist from the University of Düsseldorf.

Inevitably subjective

Gaebel considers misdiagnoses to be a deep-seated problem in psychiatry. Because while physical illnesses can be measured objectively, psychiatrists are dependent on their personal impression. "You can see a broken bone on an X-ray and diabetes on the blood sugar level," says Gaebel. Mental disorders, however, have to be recognized primarily through observation and listening.

Neurologists are also looking for measurable changes in brain waves, brain structure or brain chemistry; but they only help in exceptional cases.

"Essentially, psychiatrists have the patient's reactions and answers available," says Gaebel. Not only does a doctor need to ask the right questions, the patient needs to describe what happened to them and what they are feeling. "But not every patient can do that," says Gaebel.

Up until the 1970s, the question of how reliable a psychiatric diagnosis was unsettled the subject. At the end of the 1960s there was so much mistrust that some experts demanded that a firm diagnosis be avoided altogether.

One of them was David Rosenhan, a professor of psychology at Stanford. The Rosenhan experiment named after him is still a warning today: Between 1968 and 1972 Rosenhan and seven healthy students presented themselves in psychiatric clinics where they claimed to have heard voices.

Although the eight behaved completely normally in the clinic, none was noticed as a simulant; all of them were only discharged after three to eight weeks with a diagnosis of "schizophrenia subsided". The rate of misdiagnosis: 100 percent.

Another type of self-test, which the American Aaron Beck and four colleagues underwent in 1962, was similarly worrying. Two of the five psychiatrists examined 153 patients independently of one another and compared their results. In every second patient, the doctors had come to slightly different diagnoses; in every fifth the differences were so great that one of them had to be wrong. The rate of misdiagnosis: at least 20 percent.

Different questions - different answers

Beck and his colleagues also found out why they had come to such different conclusions: They had asked their patients different questions and thus received different answers. This knowledge became a cornerstone of modern psychiatry.

Over the past 45 years, psychiatrists and psychologists have developed rules about which questions to ask, in which order, and how the answers are to be arranged in order to give a picture of the patient. These "structured interviews" and the derived diagnoses can be found in manuals, which are updated regularly.

But even these catalogs of diseases have not solved the problem of misdiagnosis. "Even with careful use, depending on the disorder, a misdiagnosis still occurs in 20 to 40 percent of patients," concludes Hans-Ulrich Wittchen from earlier analyzes.

Another reason for the high error rate is that most patients with mental disorders show symptoms that can be assigned to different diseases.

A new diagnosis every day

"A particularly critical example" for Wolfgang Maier is the difficult distinction between a borderline disorder and a bipolar disorder. "The distinction requires a thorough examination of the curriculum vitae," says Maier. "But that is often not the case in everyday clinical practice."

The consequences are grave. Because the borderline disorder, in which people behave extremely regardless of social consequences, is preferably treated with psychotherapy; bipolar disorder with its manic and depressive phases, on the other hand, with medication.

There is another reason why psychiatrists need a lot of time to make a good diagnosis: In addition to a mental illness, more often arise over the years. For example, if a patient cannot get a panic disorder under control, they can also develop depression and become addicted to alcohol.

Cautious psychiatrists therefore make their first diagnosis only provisionally. Only the intensive care of the patient creates the basis to confirm the first suspicion, to modify it - or to drop it.

But this careful approach takes time. A thorough interview alone can easily take an hour. A resident doctor has "a total of only 40 minutes" per quarter for a patient, says Fritz Hohagen, President of the German Society for Psychiatry, Psychotherapy and Neurology. And there is a shortage of staff at the mental hospitals.

"A doctor there often has to look after 40 patients a day," says Wittchen. As a result, diagnoses are often made on the basis of a fleeting impression. "I estimate that less than every 20th diagnosis is based on structured interviews," says Wittchen.

Margret O. experienced the consequences personally. "I received six different diagnoses in ten weeks," she says. Some doctors would not have spoken to her at all before naming a new clinical picture.

The 28-year-old Karin Z. went through an odyssey. The list of diseases that doctors have found in her since puberty reads like a psychiatric dictionary: "Acute Psychosis", "Autism", "Anorexia Nervosa", "Neurosis", "Schizophrenia", "Somatoform Disorder", " social psychosis "," tardive akathisia "and four different personality disorders were attested to her.

The ingenuity only came to an end when Z. found a doctor who thoroughly examined her again - and "could not diagnose a mental illness". Now Karin Z. wants to complain: "No doctor has dealt with me and my life story in peace."

Whether such experiences are really rarities can be determined. Wittchen has shown how psychiatric misdiagnoses can be tracked down. He distributed a well-tested questionnaire for detecting depression to 15,000 people who were being treated by their family doctor.

His staff then compared the answers with the diagnoses made by the general practitioners. The result: the general practitioners had "definitely and definitely" diagnosed depression in every 11th patient without the questionnaire giving any indication of this. 1300 of the 15000 patients wore the label "depressive" wrongly.

But the psychiatrists did not scrutinize their own work, only that of general practitioners. A similar check would also be possible in psychiatric practices and clinics. "Something like that," says Wittchen, "is currently not in sight."