Patrick Keough

Patrick Keough

Large language models are increasingly deployed to simulate patients for clinical training, research, and mental health tools, yet population-level validity remains largely untested. We introduce PsychBench, the first epidemiological audit of LLM patient simulation: 28,800 profiles from four frontier models (GPT-4o-mini, DeepSeek-V3, Gemini-3-Flash, GLM-4.7) evaluated against NHANES and NESARC-III baselines across 120 intersectional cohorts. The central finding is a coherence-fidelity dissociation: models produce clinically plausible individuals while misrepresenting the populations they are drawn from. Variance compression ranges from 14 percent (GLM-4.7) to 62 percent (DeepSeek-V3), eliminating the distributional tails of clinical reality. Despite test-retest correlations above r = 0.90, 36.66 percent of cases cross diagnostic thresholds between runs. Symptom correlation matrices diverge across demographic groups beyond split-half noise, with transgender populations diverging three to five times more than racial differences. Calibration bias is systematic and asymmetric. Models overestimate depression severity for most groups by 3.6 to 6.1 points (Cohen d = 1.13 to 1.91), consistent with training on clinical corpora with elevated base rates. For transgender women the direction inverts: models capture only 8 to 46 percent of documented minority stress elevation, yielding a -5.42 residual (d = -1.55). Models also attribute irritability to Black men and fatigue to women beyond matched controls, encoding racialized and gendered assumptions. Patterns replicate across US and Chinese architectures, indicating failures tied to current training paradigms rather than isolated implementations. For most users, LLM mental health tools risk pathologizing ordinary distress; for transgender users, algorithmic erasure of genuine need. The patients look right. They do not represent real populations.

Patrick Keough

Large language models are increasingly deployed as high-stakes advisors, yet standard alignment benchmarks treat sycophancy as a binary failure mode. We introduce the Granularity Gap: coarse binary metrics mask substantial social-compliance behaviors where models capitulate to user framing, validate questionable premises, or soften factual corrections without producing overtly false outputs. We evaluate six Gemini variants across generations 2.0, 2.5, and 3.0 on 73 adversarial prompts under three guardrail conditions (Control, Simple, Protocol), yielding 8,830 graded responses. Using a 0-4 Likert scale validated against a human annotator triad (Fleiss kappa = 0.71; Cohen kappa = 0.78 vs AI consensus; 95.9 percent binary accuracy, 100 percent specificity), we quantify sycophancy as continuous rather than binary. Three findings emerge. First, 27.2 percent of responses contain substantial sycophantic content (Likert >= 2.0) and 22.7 percent reach moderate or severe levels (>= 3.0), while binary win-rate framing reports only modest failure rates; coarse metrics explain just 29 percent of graded variance. Second, generational progress is non-monotonic: Gen 2.5 regresses sharply (mean Control 2.64) relative to Gen 2.0 (1.90) and Gen 3.0 (2.01), and Gen 2.5 shows inverse scaling (Pro 1.94 worse than Flash 1.71) while Gen 3.0 restores standard scaling. Third, we document an Alignment Tax: Spearman rho = -0.63 between sycophancy and truthfulness, indicating social compliance trades against factual accuracy. Egotistical Validation prompts act as a sycophancy trap (mean 3.27), nearly double Unethical Proposals (1.72). Simple guardrails outperform elaborate Protocol scaffolding on flagship models, but distilled Gen 3.0 Flash inverts this, suggesting small models may structurally require chain-of-thought scaffolding. We release the dataset and rubric to support continuous sycophancy measurement.