On this account, a person presenting to a psychiatrist with pronounced suffering and incapacity due directly to intense, irrational hatred of a race, religion, or ethnic group would indeed be considered diseased. I hasten to add that the kind of suffering I am positing must not be due solely to the punitive consequencesof acting on bigoted beliefs, such as being thrown in jail for a racially motivated assault. The suffering must be, at least in part, "primary"—that is, a direct consequence of experiencing one's own pathological bias. Suppose, for example, a patient presented with the complaint, "Doc, I have these incredibly intense feelings of anger and hatred toward people from [country X]. I know it's crazy, and I'd like to change, but I can't. The feelings and thoughts are shameful to me, and they torment me night and day. I can hardly eat or sleep feeling this way." I would argue that to just the extent such a patient meets our broad criteria for disease—suffering and incapacity—he or she is worthy of our compassion and care.
But what about those persons—like my old nemesis, Robin Hicks—who are apparently neither suffering nor incapacitated as a direct result of their bigoted beliefs? Are they, nevertheless, sick or diseased? My personal response is, "Not in any sense that is relevant to the practice of clinical psychiatry." It is true that psychiatrists are sometimes asked—usually by the legal system—to deal with persons who have committed antisocial acts but who do not seem in any way bothered or incapacitated by their behaviors (eg, sexual predators whose pedophilia is completely ego-syntonic). These sociopathic persons represent a medicolegal dilemma, and I have no easy answer as to how our profession should deal with them. However, I would argue that they do not represent persons with disease.
Even if we agree that pathological bigotry accompanied by suffering and incapacity represents disease in a generic sense, we must still ask if it represents a specific disease that might warrant inclusion in DSM-IV.
Here, I believe, psychiatry must draw on the history of general medicine. Historically, physicians usually begin the conceptual-empirical march toward disease by first identifying a syndrome; that is, a specific set of signs and symptoms that we observe with great consistency and regularity. Such a syndrome—for example, central obesity, muscle weakness, hypertension, and amenorrhea—may ultimately be understood as a specific disease when one or more of the following criteria are met.
- A pattern of genetic transmission is discovered, sometimes leading to the identification of a specific genetic locus.
- The syndrome's pathophysiology and/or pathological anatomy becomes reasonably well understood.
- The syndrome's course, prognosis, and response to treatment are seen to be relatively predictable and uniform across many populations.
Indeed, when the features of Cushing's syndrome were traced to pituitary dysfunction, that particular condition became known as Cushing's disease.
Of course, there have been innumerable debates as to whether classic psychiatric disorders or diseases, such as schizophrenia, fully meet any of the 3 criteria described.4-6 Whatever one's view of such controversies, it seems to me that the construct of pathological bigotry has not yet reached even the syndromal level, much less the status of a specific disease.Nonetheless, our present diagnostic schema would allow us to treat such patients under a number of existing diagnostic categories, depending on the nature and severity of their pathology.
That said, there are some preliminary but intriguing data emerging from the work of Professor Edward Dunbar, of the University of California, Los Angeles, that may someday form the foundation for a pathological bias syndrome. Dunbar has developed the Outgroup Hostility Scale (OHS) for measuring the dimensions of pathological bias; for example, experiencing panic and anxiety in response to benign contact with persons of a racial or ethnic group. In a study of psychotherapy outpatients who sought treatment for problems unrelated to such bias, Dunbar found that OHS scores correlated with measures of hypomania, hostility, panic symptoms, and lower scores on the Global Assessment of Functioning (E. Dunbar, unpublished data, 2007). A history of psychological trauma was also a factor in some pathologically biased patients. Earlier work by Dunbar found that high ratings of "outgroup bias" were significantly associated with axis II criteria for paranoid, borderline, and antisocial personality disorders.7
Nonetheless, Dunbar stopped short of concluding that pathological bias should be considered a stand-alone disorder. As he noted, "the identification of specific symptoms of such a diagnostic category would need to demonstrate, via clinical research, an independence from other recognized diagnostic categories, and to . . . [confer] serious impairment to the individual such as to warrant mental health treatment" [italics added] (E. Dunbar, unpublished data, 2007). Moreover, Dunbar acknowledged that, as yet, "there are no established practice guidelines for the treatment of pathologically biased patients."
Carl Bell, MD, a psychiatrist who has written extensively in this area, rightly argued, "racism most likely has biological, psychological, and sociological origins." He added, however, that racism is "mainly a product of learned behavior" and that a "majority of explicitly racist persons do not have any psychopathology."8
In my view, it is at best premature to create a new diagnostic category for racism or bigotry. Still, to the extent that subgroups of those with pathological bias may have comorbid psychopathology—and to the extent that these persons are willing to undergo diagnosis and treatment—psychiatrists should remain actively interested and involved.