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WASHINGTON The 48-year-old man turned down a job because he feared a co-worker would be gay. He was upset that gay culture was becoming mainstream and blamed most of his personal, professional and emotional problems on the gay and lesbian movement.
These fixations preoccupied him every day. Articles in magazines about gays made him agitated. He confessed that his fears had left him socially isolated and unemployed for years. A recovering alcoholic, the man avoided 12-step meetings out of fear he might encounter a gay person.
"He had a fixed delusion about the world," said Sondra Solomon, a University of Vermont psychologist who treated the man for two years. "He felt under attack, he felt threatened."
Mental-health practitioners say they regularly confront extreme forms of racism, homophobia and other prejudice in the course of therapy, and some patients are disabled by these beliefs. As doctors increasingly weigh the effects of race and culture on mental illness, some are asking whether pathological bias ought to be an official psychiatric diagnosis.
Advocates have circulated draft guidelines and have begun to conduct systematic studies. While the proposal is gaining traction, it is still in the early stages of being considered by the professionals who decide on new diagnoses.
If it 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.
Several experts said they are unsure whether bias can be pathological. Solomon, for instance, is uncomfortable with the idea. But they agreed psychiatry has been inattentive to the effects of prejudice on mental health and illness.
"Has anyone done a word search for 'racism' in DSM-IV? It doesn't exist," said Carl Bell, a Chicago psychiatrist, referring to psychiatry's manual of mental disorders. "Has anyone asked, 'If you have paranoia, do you project your hostility toward other groups?' The answer is 'Hell, no! "
Paralyzed by fear
The proposed guidelines that California psychologist Edward Dunbar created describe people whose daily functioning is paralyzed by persistent fears and worries about other groups. The guidelines have not been endorsed by the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM); advocates are mostly seeking support for a systematic study.
Darrel Regier, director of research at the psychiatric association, said he supports research into whether pathological bias is a disorder. But he said it is unknown whether a diagnostic classification would add anything useful, given that clinicians already know about disorders in which people rigidly hold onto false beliefs.
"If you are going to put racism into the next edition of DSM, you would have enormous criticism," Regier said. Critics would ask, " 'Are you pathologizing all of life?' You better be prepared to defend that classification."
"I think it's absurd," said Sally Satel, a psychiatrist and author of "PC, M.D.: How Political Correctness Is Corrupting Medicine." Satel said the diagnosis would allow hate-crime perpetrators to evade responsibility by claiming they had a mental illness. "You could use it as a defense."
Psychiatrists who advocate a new diagnosis, such as Gary Belkin, deputy chief of psychiatry at New York's Bellevue Hospital Center, said social norms play a central role in how all psychiatric disorders are defined. Pedophilia is considered a disorder by psychiatrists, Belkin noted, but that does not keep child molesters from being prosecuted.
"Psychiatrists who are uneasy with including something like this in the Diagnostic and Statistical Manual need to get used to the fact that the whole manual reflects social context," said Belkin, who is planning to start a study on pathological bias among patients at his hospital. "That is true of depression on down. Pathological bias is no more or less scientific than major depression."
Advocates for the new diagnosis also say most candidates for treatment, such as the man Solomon treated, are not criminals or violent offenders. Rather, they are like the woman in Los Angeles who thought Jews were diseased and would infect her; she carried out compulsive cleansing rituals and hit her head to drive away her obsessions.
She realized she needed help but was afraid her therapist would be Jewish, said Dunbar, a Los Angeles psychologist who has amassed several case studies and treated several dozen patients for racial paranoia and other forms of what he considers pathological bias.
Another patient was a waiter so hostile to black people that he flung plates on the table when he served black patrons and got fired from multiple jobs.
A third patient was a Vietnam War veteran who was so fearful of Asians that he avoided social situations where he might meet them, Dunbar said.
"When I see someone who won't see a physician because they're Jewish, or who can't sit in a restaurant because there are Asians, or feels threatened by homosexuals in the workplace, the party line in mental health says, 'This is not our problem,' "' the psychologist said. "If it's not our problem, whose problem is it?"
Opponents say making pathological bias a diagnosis raises the specter of social engineering, brainwashing individuals who do not fit society's norms. But Dunbar and others say patients with disabling levels of prejudice should be treated for the same reason as are patients with any other disorder: They would feel, live and function better.
"They are delusional," said Alvin Poussaint, a professor of psychiatry at Harvard Medical School, who has long advocated such a diagnosis. "They imagine people are going to do all kinds of bad things and hurt them, and feel they have to do something to protect themselves.
"When they reach that stage, they are very impaired. They can't work and function; they can't hold a job. They would benefit from treatment of some type, particularly medication."
Doctors who treat inmates at the California State Prison outside Sacramento concur: They have diagnosed some forms of racist hatred among inmates and administered anti-psychotic drugs.
"We treat racism and homophobia as delusional disorders," said Shama Chaiken, who later became a divisional chief psychologist for the California Department of Corrections, at a meeting of the American Psychiatric Association. "Treatment with anti-psychotics does work to reduce these prejudices."
Bell, the Chicago psychiatrist, said he has not made up his mind on whether bias can be pathological. But in proposing a research agenda for the next edition of psychiatry's DSM of mental disorders, Bell and researchers from the Mayo Clinic, McGill University, the University of California, Los Angeles and other academic institutions wrote:
"Clinical experience informs us that racism may be a manifestation of a delusional process, a consequence of anxiety, or a feature of an individual's personality dynamics."