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Rosenhan chose these symptoms because of their similarity to existential symptoms experienced by normal people. The patients altered their names and vocations, but otherwise gave accurate renditions of their present circumstances and past psychological history. They had no other psychiatric symptoms.

Seven of the eight were diagnosed as schizophrenic and hospitalized for an average of 19 days. (The other patient was diagnosed as manic-depressive). They stopped feigning the hearing of voices shortly after admission. During their hospitalization, none were found out and all were discharged with a diagnosis of schizophrenia in remission. One third of the ward patients questioned felt certain, or at least suspected, that the pseudo-patients were sane. The staff raised no such doubts.

Of course there were the usual protestations, criticisms, and general article nit-picking, but the point was obvious. Evidence-based psychiatry was just emerging, challenging the more traditional anecdotal case-history approach. Shrinks still believed that they could stroke their beards and exclaim, "In my experience ..." (Can you imagine what would happen to psychics if they had to publish statistical analysis of their crystal-ball utterances)?

About this time I had a singularly unnerving medical experience. After my residency, I became the neurology consultant for a nearby state mental hospital. I interviewed a teenage mother incarcerated for having shaken her young daughter to death when she wouldn't stop crying. During a subsequent evaluation on the psych ward at County Hospital, she had tried to choke a weeping, demented 90-year-old wheelchair-bound woman.

Sitting across the consultation desk from the attractive, fresh-faced mother (two burly guards stood alongside), I soon realized that I had no idea what, if anything, was wrong with her. She could have been a poster girl for the 4-H Club. Nothing was obvious; her demeanor, speech, neurological history and exam were all normal. After we finished, I asked her why she'd tried to choke the old woman. The patient answered dryly, without a hint of emotion, "I hate the sound of crying."

I still remember her staring at me as though she, too, were puzzled by her behavior. No one, including herself, understood her. Sane? Insane? Cunning? I had no idea, nor even a clue as to how to make such a determination. I knew that the psychiatrists were more skilled than I, but to what degree? I had the sinking feeling that accuracy of prediction would be an afterthought in the way that a cloud is a rain cloud only after it starts to dump rain. I thought of the Rosenhan study and was glad I was not the presiding judge.

Three psychiatrists judged the woman mentally incompetent to stand trial; she was shipped to the state facility for the criminally insane. She would receive the usual treatment, until one day a court-appointed psychiatrist would be put to the test -- "Is she still dangerous?"

I do not know what happened to the woman. (She was transferred from hospital to hospital until I lost track of her.) But here are some sobering statistics on psychiatrists' ability to pick out subsequent violent patients. I do not offer them as specific criticism of psychiatry, but rather as a not-so-palatable dose of realism. It's time we take a hard look at the limits of assessment of future behavior.

A study at a New York psychiatric hospital, published last month, analyzed the ability of the treating psychiatrists to predict who, among 183 male patients, were likely to show assaultive behavior during the following three-month period. Their accuracy rate was 71 percent; 29 percent of future violent patients were not identified.

In a 1993 study, members of the department of psychiatry, University of Pittsburgh School of Medicine, evaluated patients originally seen in the emergency department of a metropolitan psychiatric hospital. When ready for discharge, the patients were assessed for their potential for violence and accordingly assigned to one of two groups -- violent or nonviolent. In a six-month follow up, violent acts occurred in half of the cases predicted to be violent, but also in over one-third of the "nonviolent" group. Within this group, predictions of female patients' violence were not better than chance (flipping a coin was equal to a psychiatric evaluation).

The same authors then took the same group of patients and compared the predictive capabilities of the examining psychiatrists to actuarially derived data gathered from the patients' histories. Computer-assessment was found to be more accurate than assessments by the treating clinicians.

In another study, such intuitively obvious differences as verbal threats versus actual prior physically assaultive behavior haven't been shown to accurately predict subsequent violent behavior.

Why do clinicians consistently miss a third of subsequently violent patients? In large part, the answer lies in the huge overlap between normal and abnormal behavior. There are no clear cut-offs between the truly dangerous vs. those posing only idle threats. Trying to improve the sensitivity of our predictions would necessarily erroneously categorize a major percentage of psychiatric patients. I can't help wondering how Van Gogh would have been classified after he cut off his ear. Would gentle Vincent, who never hurt a sunflower, have been classified as dangerous?

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