Classifying bias: When does it become a mental illness?



John Dovidio, Ph.D. psychology professor at the University of Connecticut, says that the forces that can lead to even extreme prejudice are rooted in normal and typical psychological processes. (photo by Tom Croke)

By Nan Shnitzler

With the advent of the next version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-V, the debate over the impact of race and culture on mental illness is about to heat up. Should pathological bias, encompassing racism, homophobia and religious prejudice, be considered an official psychiatric diagnosis?

While the issue is extremely complex with societal, legal and financial ramifications, Alvin Poussaint, M.D., Harvard Medical School psychiatry professor, has been making his argument for years that extreme bias is mental illness.

Bias can be regarded like other mental health problems that manifest themselves on a continuum, for example, from sadness to diagnosable major depression, Poussaint says. A moderate amount of racial bias, like moving out of an increasingly mixed neighborhood, is not mental illness. But a person overly preoccupied with race, who thinks blacks and Jews are responsible for all the ills of the world, is delusional, suffers from a disorder and needs help.

"It's the extreme form, the final form, the person ready to go out and commit genocide that has to be called mentally ill," Poussaint says. "You have to draw the line. When it reaches a certain point, there's a threshold issue for me."

He says that pathological bias should not necessarily be a whole new category of diagnosis. Just as in the current DSM where there is delusional disorder-jealousy type or -grandiose type, Poussaint thinks there should be delusional disorder-prejudice type.

"You should be able to use DSM to specifically say, for example, this is schizophrenia with the core component delusions around race," Poussaint says. "The DSM committee should look at where race is a relevant issue and explore it from the mental health standpoint in all these categories."

John Dovidio, Ph.D., psychology professor at University of Connecticut, argues against classification. He worries that if treatment were targeted to the relatively few extreme cases, then it would define the problem as pathological only, thus overlooking all the other social dynamics that operate to keep prejudice alive.

"People would say, why study everyday racism when the real problem is hate crime?" Dovidio says. "I'm saying, that's not the real problem; that's just the extreme end."

Dovidio makes a case that the psychological forces that can lead to even extreme prejudice are rooted in normal and typical psychological processes.

Research shows that sorting people into groups, even arbitrarily, is enough to generate biases towards others not in the group; that people who feel insecure will engage in prejudice to raise their self-esteem; and to ensure survival, people secure resources for their group at the expense of other groups.

If discrimination and prejudice serve a normal function, then they cannot be the root cause of psychological problems. Prejudice is a symptom, Dovidio says. If you make anti-Semites feel better about Jews, for example, they would probably focus their hate on another group because the prejudice is serving some underlying function.

"What needs to be treated is what's causing them to act out in that particular way," Dovidio says. "The idea of using it as a diagnostic category is simply inverting what's a symptom and what's a problem."

The American Psychiatric Association publishes the DSM. Each mental disorder has a list of diagnostic criteria that indicates what signs and symptoms must be present and for how long in order to qualify for a diagnosis. Associated with each diagnosis is a code used for data collection, insurance and billing.

The diagnostic code follows patients around for the rest of their lives, says Herbert Nieburg, Ph.D. He doesn't think the world needs any more.

Most forms of prejudice are a political statement about how people feel about other people of different social orientations, says Nieburg, who runs Southeast Counseling Associates in Pawcatuck, Conn. In it most severe form, he thinks bias belongs to existing diagnostic classifications such as personality or anxiety disorder. He also thinks classifying pathological bias has potential for abuse.

"I can just see someone in a position of power or authority abusing someone who is homosexual then using homophobia as a defense," Nieburg says. "Or the black rage defense that says I'm African American, I've been mistreated by society and my actions aren't under my control."

Poussaint thinks psychiatry has ignored bias. One reason is because the continuum of mental illness he describes conflicts with DSM's standardized diagnostic criteria. The American Psychiatric Association is looking at the issue with DSM-V.

"It will be a challenge to tackle how categorical diagnoses can be reconciled with dimensional scales, a better descriptor of the subtleties of human behavior," says William E. Narrow, M.D., M.P.H., associate director for diagnosis and classification at the American Psychiatric Association. "But we can't give up categories because they have big advantages in being able to communicate with people outside the field."

Another reason is because exploring bias means getting into cultural issues, which could expose the field to claims of social engineering or medicalizing social problems.

It's a legitimate issue, says Carl C. Bell, M.D., head of Community Mental Health Councils in Chicago. Because western psychiatry is such a European American invention, healing tactics of other cultures aren't seen to add much value, he says.

A third reason psychiatry snubs bias is because the cultural underpinnings aren't backed by a body of statistical research. That could be about to change.

Bell is the de facto leader of the movement to research bias with controlled studies. In the 2002 "Research Agenda for DSM-V," put out by the American Psychiatric Association and the National Institute of Mental Health, Bell and colleagues contribute to chapters on psychiatric diagnosis and personality disorders.

"It is clear that an accurate psychiatric diagnosis, with all the progress made so far, requires still an extraordinary series of research initiatives, particularly from the socio-cultural domain," they write.

The research agenda will eventually have associated workgroups to review the literature, evaluate public comment, recommend specific research and write draft diagnostic criteria. With every edition of DSM, researchers say they strive for more scientific and evidence-based results. Bell agrees with this approach.

"If you did a study, which has never been done, to show that all paranoid schizophrenics are pathologically biased against racial groups other than their own, that could legitimately become a diagnostic criteria for paranoia instead of there being a complete void," Bell says. "We've got to be able to tease out this issue a little better."

American Psychiatric Association spokesman Jason Young says the organization is not yet at the point of evaluating specific new proposals like pathological bias, but that advocates for certain DSM changes tend to proceed on independent tracks. He describes the process of adding new material to DSM like tossing things into a funnel and seeing what makes it through. At this point, he says, "we're debating more what the funnel will look like."

DSM-IV came out in 1994 and was revised in 2000. DSM-V is due to come out in 2011, in conjunction with an update of the World Health Organization's International Classification of Diseases.

For more information, see the DSM-V Prelude Project Web site at www.dsm5.org.

Classifying bias: When does it become a mental illness? (March 2006 Issue)

Classifying bias:
When does it become a mental illness?
(March 2006 Issue)