Notes on the BBC Feature 'How Mad Are You?'

‘How Mad Are You?’ is a two part 2008 BBC Horizon/Discovery Channel Co-Production produced and directed by Rob Liddell. The program explores the relationship between character traits and mental illness and considers the social implications of inaccurate diagnosis of the latter. Ten volunteers, five of whom have been previously diagnosed with psychiatric disorders, are observed and interviewed by a panel of three mental health experts who then venture their diagnoses. The experts include a psychiatrist, a professor of clinical psychology, and a psychiatric nurse. The volunteers and experts have no prior knowledge about one another, and were brought together for this one week study.

The program was inspired by the 1972 ‘Rosenhan Experiment,’ in which the American psychologist David Rosenhan and several associates feigned auditory hallucinations in order to have themselves admitted to psychiatric hospitals. Eight of these ‘pseudopatients’ were diagnosed with psychiatric disorders. Although they ceased displaying any symptoms once admitted to a hospital, they were detained for between 17 and 52 days. None were recognized by hospital staff. The experiment’s results, published in the journal Science in 1973, raised questions about the validity of psychiatric diagnosis.

Part One introduces the three experts and ten volunteers and explains that the goal of the study is to attempt to recognize six forms of mental illness: depression, social anxiety disorder, schizophrenia, obsessive-compulsive disorder, bipolar disorder and the eating disorders anorexia and bulimia. The panel of experts has one week of observation to identify whether or not any of the volunteers has one of these illnesses. Before beginning, the panelists discuss the insufficient time for a proper psychiatric diagnosis but appear willing to accept the challenge and lend their expertise to the study.

The ten volunteers complete a variety of tasks designed to determine symptoms of mental illness. The first task is to perform a stand up comedy routine in front of a small audience in a pub. Several of the volunteers have difficulty with this task but for the panel the results are inconclusive. As part of the study the panel makes daily predictions as to which volunteers may later be diagnosed with one or another of the six mental disorders. The second task involves problem solving skills and it utilizes the Wisconsin card sorting test for determining bipolar disorder, schizophrenia and obsessive compulsive disorder (OCD). The results are also inconclusive but the panel begins to focus attention on one of the volunteers. The third task involves cleaning up after farm animals, after which the panel is allowed to interview one volunteer. This interview yields the first clear indication that one of the volunteers may be suffering from OCD. The interview is followed by an explanation of OCD and a set of short interviews in which the volunteers are asked about their perceptions of one another.

By the end of the fourth task, designed to detect depression, the panel found that their observations contradicted earlier predictions, with the narrator noting ‘greater confusion is not what the panel was hoping for.’ As the panel will attempt their first diagnosis after the next task, they discuss their observations so far, which is made more complicated because none of the volunteers indicates the classic signs of depression. This segment is followed by background information about depression.

After the fifth task, a paintball team competition designed to display leadership and teamwork, the panel selects a single volunteer for an extended interview. They are then asked to make their first diagnosis by identifying one volunteer that they think has a mental disorder and one that appears to be normal. This segment is significant because although the conditions are not optimal for a proper psychiatric diagnosis, psychiatry is a profession and as such is expected by society to produce results. The panel takes this seriously and compares notes on the ten volunteers, because, as the narrator suggests, ‘one person here might be about to discover their mental illness marks them out from the group,’ while another person ‘could be burdened with a label of a disorder they don’t actually have.’

The panel is able to correctly identify the volunteer with OCD, based on their observation of his handling of the farm animal cleanup task, and this is followed by an enlightening discussion with the volunteer about life with OCD, in which he expresses his hope that his participation in the study can encourage other OCD sufferers to come to terms with their disorder and seek treatment. However, the panel was incorrect in their selection of a normal volunteer. Despite three days of intensive observation the panel failed to notice that this volunteer had a history of mental illness. In the follow up interview, the volunteer expresses relief that she was not identified as having a mental disorder, stating that her ‘worst fear was that I would be found out on day one,’ adding that the whole point of the program for her was to ‘show that it isn’t obvious.’ Part One concludes with the panelists reflecting on the study so far, with one expert noting that the latter case ‘refutes the argument that if you have a mental health problem, a) you can tell by looking at someone, and b) your life’s over.’ This is further amplified by the producer and director Rob Liddell, who has suggested that airing such concerns is the point of the program: ‘They all tell a powerful story, that having a mental illness doesn't have to become your defining characteristic and that it shouldn't set you apart in society.’

Part Two opens with a map orienteering task that involves running, teamwork, leadership skills and problem solving, returning to the question of whether or not difficulty with such tasks would be due to mental disorder or simply related to character traits. This again raises the point that diagnoses in this study are based only on observation and interviews over a short period of time, not on the usual clinical procedures. However, the experience remains valuable for what it can reveal about the social implications of labeling and in particular the related problem of social stigma. In fact, the issue of social stigma as the result of diagnosis (correct or incorrect) seemed to be of prime importance to some of the volunteers, while the panel of experts took risks that are potentially present for any mental health professional, that there are social implications of identifying people with disorders, for failing to recognize mental disorders, and in labeling someone with a disorder that they do not have.

The next two segments include the tasks and background information related to bipolar disorder and eating disorders, with the latter involving a body image test that reiterates one main point of the study: whether or not discomfort with a situation is an indication of mental illness. The body image test began with the participants photographing one another in tight fitting attire, followed by a computer test in which they are asked to correct a distorted body image of themselves. This leads to the next major diagnosis in the program, in which the panel correctly identifies a volunteer with anorexia nervosa, and is followed by interviews with the volunteers on life with various disorders.

Designed to test perception of self with others, one of the most interesting tasks utilizes a computer simulation to illicit paranoid reaction, featuring a virtual reality environment that simulates being on a train among strangers. All characters on the virtual train were programmed to be neutral, but volunteers were asked if any stood out or seemed to be looking at them, which was expected to help determine if any volunteers were imagining that they were being watched. This task raised questions about social exclusion versus paranoid delusion, and was followed by information on schizophrenia. The final task considered decision making by observing if any volunteers jumped to conclusions when asked from which jar different colored marbles had been drawn after being shown jars with differing amounts of each color, even though all marbles were actually drawn in the same sequence from a tray, not from the jars initially shown to the subjects. This raises valuable questions about the experimental method, because various responses were evaluated with averages and norms ultimately determining the basis for a diagnosis, as it is with most other medical professions.

After conducting another in-depth interview with a volunteer and after noting that the borderlines between mental illness and health are often arbitrary, the panellists make three wrong diagnoses in a row. They incorrectly concluded that one volunteer had bipolar disorder and another had a mood disorder (although one of these two had indeed suffered from depression), and they incorrectly concluded that one volunteer had a history of schizophrenia, while no such history existed. By the end of the study, the volunteers with OCD and an eating disorder were correctly identified, but two volunteers with mental disorders had remained undetected (those with social anxiety and bipolar disorders), and two others without disorders were wrongly identified as having disorders, while a another was diagnosed with a different disorder than the one that she actually had. In a series of follow up interviews, a few of the volunteers appear to feel vindicated by the inability of the experts to diagnose psychiatric disorders, while one of the panelists admits that ‘we have been humbled.’

Although it appears to unfairly burden the experts who are asked to diagnose with insufficient data, the program makes the broader point that if the experts cannot tell who has a mental illness and who does not through observation then certainly the public ought to refrain from making any such judgments. Perceptions and observations, whether from experts or the public, are not enough to be sure about mental illness, which often takes long term systematic evaluation to determine. At the same time there are very real and potentially damaging social implications of labeling people with a mental illness, because those who are labeled may then become stigmatized while those who are undiagnosed may be reluctant to seek help if they feel revealing their disorder will stigmatize them.

While the program readily acknowledges the limitations of short term observation, there are other equally important issues with this study that are left unacknowledged. For example, gender issues are not explored at all, which seems to be an odd exclusion since the panelists were all male and four of the five volunteers that they identified (either correctly or incorrectly) as having psychiatric disorders were women. Nevertheless, the study is useful in that it has provided insights on various mental illnesses and the diagnostic process, letting both the doctors and patients share their views openly, while its overall message of being prudent in identifying mental illness and tolerant toward those who have mental illness cannot be emphasized enough, and even needs further amplification, because labeling and social stigma remain as serious implications for all mental health practitioners.

‘How Mad Are You’ originally aired on the BBC and affiliate stations in November 2008, and is occasionally available for viewing on various viral media sites. The Rosenhan study, ‘On Being Sane In Insane Places,’ was originally published in the journal Science in January 1973 and is available online, and the quote from Rob Liddell is from his article ‘How Mad Are You?’ on the BBC News website, in its 18 November 2008 Magazine section.

[This review is by Yusef Progler and was originally published in the Journal of Research in Medical Sciences, vol. 14, no. 5, 2009.]