[tt] [technoliberation] Is Bigotry a Mental Illness?

[Eugen Leitl]

----- Forwarded message from "Hughes, James J." <James.Hughes at trincoll.edu> -----

From: "Hughes, James J." <James.Hughes at trincoll.edu>
Date: Tue, 3 Jul 2007 12:18:53 -0400
To: technoliberation at yahoogroups.com
Subject: [technoliberation] Is Bigotry a Mental Illness?
Reply-To: technoliberation at yahoogroups.com

	
http://www.psychiatrictimes.com/showArticle.jhtml?articleID=199202755	

May 01, 2007 Vol. 24 No. 6

Is Bigotry a Mental Illness?

Ronald Pies, MD
	

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."

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.

    * 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.

References
1. 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.


 
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Eugen* Leitl <a href="http://leitl.org">leitl</a> http://leitl.org
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