The Psychopath Test

by Jon Ronson

complicated human behaviour was increasingly getting labelled a mental disorder. How did this come to be? Did it matter? Were there consequences?

When Rosenhan reported the experiment there was pandemonium. He was accused of trickery. He and his friends had faked mental illness! You can’t blame a psychiatrist for misdiagnosing someone who presented himself with fake symptoms! One mental hospital challenged Rosenhan to send some more fakes, guaranteeing they’d spot them this time. Rosenhan agreed, and after a month the hospital proudly announced they had discovered forty-one fakes. Rosenhan then revealed he’d sent no one to the hospital.

Someone would yell out the name of a potential new mental disorder and a checklist of its overt characteristics, there’d be a cacophony of voices in assent or dissent, and if Spitzer agreed, which he almost always did, he’d hammer it out then and there on an old typewriter, and there it would be, sealed in stone. It seemed a foolproof plan. He would eradicate from psychiatry all that crass sleuthing around the unconscious. There’d be no more silly polemicizing. Human judgement hadn’t helped his mother. Instead it would be like science. Any psychiatrist could pick up the manual they were creating – DSM-III – and if the patient’s overt symptoms tallied with the checklist they’d get the diagnosis. And that’s how practically every disorder you’ve ever heard or have been diagnosed with came to be invented, inside that chaotic conference room, under the auspices of Robert Spitzer, who was taking his inspiration from checklist pioneers like Bob Hare.

DSM-III was a sensation. Along with its revised edition, it sold more than a million copies. Sales to civilians hugely outweighed sales to professionals. Many more copies were sold than psychiatrists existed. All over the Western world people began using the checklists to diagnose themselves. For many of them it was a godsend. Something was categorically wrong with them and finally their suffering had a name. It was truly a revolution in psychiatry, and a gold rush for drug companies who suddenly had hundreds of new disorders they could invent medications for, millions of new patients they could treat. ‘The pharmaceuticals were delighted with DSM,’ Spitzer told me, and this in turn delighted him: ‘I love to hear examples of parents who say, “It was impossible to live with him until we gave him medication and then it was night and day.”

Dr Frances told me over the phone he felt they’d made some terrible mistakes. ‘It’s very easy to set off a false epidemic in psychiatry,’ he said. ‘And we inadvertently contributed to three that are ongoing now.’ ‘Which are they?’ I asked. ‘Autism, attention deficit, and childhood bipolar,’ he said. ‘How did you do it?’ I asked. ‘With autism it was mostly adding Asperger’s, which was a much milder form,’ he said. ‘The rates of diagnosis of autistic disorder in children went from less than one in two thousand to more than one in one hundred. Many kids who would have been called eccentric, different, were suddenly labelled autistic.’ I remembered my drive to Coxsackie Correctional Facility, passing that billboard near Albany – every 20 seconds a child is diagnosed with autism. Some parents came to wrongly believe that this sudden, startling outbreak was linked to the MMR vaccine. Doctors like Andrew Wakefield and celebrities like Jenny McCarthy and Jim Carrey promoted the view. Parents stopped giving the vaccine to their children. Some caught measles and died. But this chaos, Allen Frances said, pales next to childhood bipolar. ‘The way the diagnosis is being made in America was not something we intended,’ he said. ‘Kids with extreme irritability and moodiness and temper tantrums are being called bipolar. The drug companies and the advocacy groups have a tremendous influence in propagating the epidemic.’

‘There’s a societal push for conformity in all ways,’ he said, ‘there’s less tolerance of difference. And so maybe for some people having a label is better. It can confer a sense of hope and direction. “Previously I was laughed at, I was picked on, no one liked me, but now I can talk to fellow bipolar sufferers on the Internet and no longer feel alone.” ’ He paused. ‘In the old days some of them may have been given a more stigmatizing label like conduct disorder or personality disorder or oppositional defiant disorder. Childhood bipolar takes the edge of guilt away from parents that maybe they created an oppositional child.’

‘Has anyone studied whether bipolar children still get the diagnosis when they reach adolescence?’ I asked Bryna. ‘Yeah,’ she said. ‘Some do. Others outgrow it.’ ‘Outgrow it?’ I said. ‘Isn’t bipolar considered to be lifelong? Isn’t that another way of saying they didn’t have it to begin with?’ Bryna shot me a sharp look. ‘My husband grew out of his asthma and food allergies,’ she said.

When I asked Robert Spitzer about the possibility that he’d inadvertently created a world in which some ordinary behaviours were being labelled mental disorders, he fell silent. I waited for him to answer. But the silence lasted three minutes. Finally he said, ‘I don’t know.’ ‘Do you ever think about it?’ I asked him. ‘I guess the answer is I don’t really,’ he said. ‘Maybe I should. But I don’t like the idea of speculating how many of the DSM-III categories are describing normal behaviour.’ ‘Why don’t you like speculating on that?’ I asked. ‘Because then I’d be speculating on how much of it is a mistake,’ he said. There was another long silence. ‘Some of it may be,’ he said.

Who was Tony? Was he Toto Constant, who had struck me as the archetypal Bob Hare psychopath, charming and dangerous, conforming to the checklist with an uncanny, eerie precision? Was he Al Dunlap, who had, I felt in retrospect, been a bit shoehorned by me into the checklist, even if he had himself laid claim to many of the items, seeing them as manifestations of the American Dream, the entrepreneurial spirit? Was he David Shayler, his insanity palpable but harmless to other people, reduced to a plaything for the benefit of the madness industry? Or was he Rebecca Riley or Colin Stagg, wrongly judged insane because they just weren’t what the people around them wanted them to be? They were just too difficult, just not normal enough.

I wondered if sometimes the difference between a psychopath in Broadmoor and a psychopath on Wall Street was the luck of being born into a stable, rich family.

‘Ever since I went on a Bob Hare course I’ve believed that psychopaths are monsters,’ I said, ‘they’re just psychopaths, it’s what defines them, it’s what they are.’ I paused. ‘But isn’t Tony kind of a semi-psychopath? A grey area? Doesn’t his story prove that people in the middle shouldn’t necessarily be defined by their maddest edges?’ ‘I think that’s right,’ he replied. ‘Personally I don’t like the way Bob Hare talks about psychopaths almost as if they are a different species.’

I would also say you can never reduce any person to a diagnostic label.

(‘Friends are the fruit cake of life – some nutty, some soaked in alcohol, some sweet . . .’)

I think the madness business is filled with people like Tony, reduced to their maddest edges. Some, like Tony, are locked up in DSPD units for scoring too high on Bob’s checklist. Others are on TV at 9 p.m., their dull, ordinary, non-mad attributes skilfully edited out, benchmarks of how we shouldn’t be. There are obviously a lot of very ill people out there. But there are also people in the middle, getting over-labelled, becoming nothing more than a big splurge of madness in the minds of the people who benefit from it.

‘I think my Broadmoor guy is a semi-psychopath,’ I said. Bob shrugged. He didn’t know Tony. ‘So should we define him by his psychopathy or by his sanity?’ I said. ‘Well, the people who say that kind of thing,’ Bob said, ‘and I don’t use this in a pejorative way, are very left-wing, left-leaning academics. Who don’t like labels. Who don’t like talking about differences between people.’ He paused. ‘People say I define psychopathy in pejorative terms. How else can I do it? Talk about the good things? I could say he’s a good talker. He’s a good kisser. He dances very well. He has good table manners. But at the same time he screws around and kills people. So what am I going to emphasize?’ Bob laughed, and I laughed too. ‘Ask a victim to look at the positive things and she’ll say, “I can’t. My eyes are swollen,” ’ Bob said.

The TV was on in the background. There was a show on about how Lindsay Lohan was ‘losing it Britney-style’.

There is no evidence that we’ve been placed on this planet to be especially happy or especially normal. And in fact our unhappiness and our strangeness, our anxieties and compulsions, those least fashionable aspects of our personalities, are quite often what lead us to do rather interesting things.