There were only 3 Jewish students in my high school, and I was one of them. In the small, western New York town where I grew up, most people were tolerant. But a small clique of anti-Semites made life tough for us Jewish kids. Most of the time, we just shrugged off the jokes and insults or came right back at these louts with a snappy retort. Sometimes, the bigotry grew more menacing.
The Second Temple was destroyed because of causeless hatred. Perhaps the Third will be rebuilt because of causeless love."
-Rabbi Abraham Isaac Kook
There were only 3 Jewish students in my high school, and I was one of them. In the small, western New York town where I grew up, most people were tolerant. But a small clique of anti-Semites made life tough for us Jewish kids. Most of the time, we just shrugged off the jokes and insults or came right back at these louts with a snappy retort. Sometimes, the bigotry grew more menacing. I still remember Robin Hicks (not his real name) walking up to me in the hallway, looking me square in the eyes, and very calmly saying, "Jews don't live long, you know."
This brief autobiographical vignette is simply to show that bigotry is of more than mere academic interest to me. I am therefore quite invested in the outcome of a controversy that has arisen recently in our profession; namely, whether or not "pathological bigotry" should be considered a psychiatric disorder. I use the term "pathological bigotry" to encompass a variety of related terms, including "pathological hatred," "racial paranoia," "extreme racial bias," and "pathological bias."
Psychiatric Times Poll
A piece in the Washington Post1 provided an excellent snapshot of how opinion on this issue has divided members of the psychiatric and academic communities-including several esteemed colleagues whom I greatly respect. As the Post reporter noted, the stakes are high. "Advocates have circulated draft guidelines [for making pathological bias an official DSM diagnosis] and have begun to conduct systematic studies. . . . If [the proposal] succeeds, it could have huge ramifications on clinical practice, employment disputes, and the criminal justice system. Perpetrators of hate crimes could become candidates for treatment, and physicians would become arbiters of how to distinguish 'ordinary prejudice' from pathological bias."1
Those who advocate making pathological bigotry a formal psychiatric diagnosis argue: Psychiatrists and other mental health professionals regularly confront extreme forms of racism, homophobia, and other forms of irrational hatred. Many patients holding these views are troubled and sometimes even disabled by them. Some individuals with pathological bigotry are frankly delusional, perceive themselves as "under attack," and become overtly dangerous to themselves or others. We should provide diagnosis and treatment for these individuals because we may be able to help them, just as we can help other troubled patients. For example, some extremely hateful patients may be helped with psychotherapy or antipsychotic medication. Psychiatric diagnosis cannot avoid the social context of mental illness, and the mere fact that our diagnoses may be misused in the criminal justice system should not deter us from applying them.
Those who oppose medicalizing these forms of bigotry argue: It is a mistake to pathologize a widespread form of human stupidity. Psychiatrists have enough trouble now, justifying the reality of ADHD and "conduct disorder"-do we really need the added woes attendant to our declaring bigotry a mental disorder? How would we differentiate mere dislike of some minority groups from pathological bigotry? Would we want this diagnosis to be a mitigating factor in, say, a violent crime against a member of a minority group? Most people who hold these bigoted attitudes are not psychotic; most probably learned their attitudes from their parents. Moreover, these individuals are rarely troubled by their beliefs. What motivation would they have for seeking or accepting "treatment"? When faced with such hateful individuals, psychiatrists should focus on diagnosing and treating well-validated, comorbid conditions, such as paranoid schizophrenia.
Both sides make good points. In order to resolve these seemingly irreconcilable views, I believe we first need to build a conceptual framework for determining what counts as disease in psychiatry; second, we can compare pathological bigotry to our paradigm and try to determine to what degree it coincides; third, we must consider how the general construct of disease relates to the further determination of whether a particular set of signs and symptoms constitutes a specific disease; and finally, we need to examine the preliminary empirical data that have emerged from some recent studies of pathological bias.
I have argued for more than 25 years that our concept of disease grew out of an ancient tradition based on the recognition of suffering and incapacity.2 In the first place, medical specialists do not diagnose disease by using high-tech imaging devices or laboratory tests, although these may help determine the specific disease entity. In psychiatry, as in general medicine, it is often a family member or soon-to-be patient who first recognizes that something is terribly wrong. This is based on our ordinary perception of suffering and incapacity in the absence of an obvious external cause, such as a knife wound. A mother who observes that her son has been tormented for months by "voices telling him to kill himself," has stopped eating and bathing, and has barricaded himself in his room for 2 weeks does not need a specialist to tell her that her son is "sick" or "diseased." Indeed, the term "disease" arose from our everyday awareness that certain pathological states leave us without ease or comfort-hence, the now obsolete word "diseasy," to describe such persons. While there is no written-in-stone, "essential" definitionof the term "disease"-that is, no list of necessary and sufficient conditions that invariably applies-I believe that the presence of marked suffering and incapacity is a good starting point for defining what philosopher Ludwig Wittgenstein might have called the "family traits" of disease entities.3
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.
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.
References1. Vedantam S. Psychiatry ponders whether extreme bias can be an illness. Washington Post. December 10, 2005: A1. Available at: www.washingtonpost.com/wp-dyn/content/article/2005/12/09/AR2005120901938.html. Accessed February 28, 2007.
2. Pies R. On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry. 1979;36:139-144.
3. Wittgenstein L. The Blue and Brown Books: Preliminary Studies for the "Philosphical Investigations," New York: Harper Colophon Books; 1958.
4. Pies R. Moving beyond the "myth" of mental illness. In: Schaler JA, ed. Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics. Chicago: Open Court; 2004: 327-353.
5. Szasz T. Schizophrenia:The Sacred Symbol of Psychiatry. New York: Basic Books; 1976.
6. Schramme T. The legacy of antipsychiatry. In: Schramme T, Thome J, eds. Philosophy and Psychiatry. New York: De Gruyter; 2004:94-119.
7. Dunbar E. The relationship of DSM diagnostic criteria and Gough's Prejudice Scale: exploring the clinical manifestations of the prejudiced personality. Cult Divers Ment Health. 1997;3:247-257.
8. Bell C. Racism: a mental illness? Psychiatr Serv. 2004; 55:1343.