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Interview- Part Two: How Current Events Affect the "Diagnosis Bible", the DSM

posted Oct 12, 2018, 8:18 AM by Rahni Jere Sumler   [ updated Jan 11, 2019, 8:34 AM by Rahni Sumler ]
Originally published on Psychology Today from Christopher Lane, Ph.D. 

In the late-1960s, schizophrenia's profile as a disease changed dramatically. This is part 2 of an interview series where Dr. Chritopher Lane interviews Dr. Jonathan M. Metzl, MD, PhD, author of The Protest Psychosis: How Schizophrenia Became a Black Disease. He is dedicated to illuminating issues of mental illness and gun violence, with a particular focus on gender and race.
Dr. Metzl is also Director of the Center for Medicine, Health, and Society at Vanderbilt University, a Psychiatrist, and the Research Director of the Safe Tennessee Project, a non-partisan, volunteer-based organization that is concerned with gun-related injuries and fatalities in America and in Tennessee. 

How would you explain that shift, and would you view American psychiatry in those years as exhibiting either manifest or unconscious racism? Was it just coincidence that the DSM-II language enabled the diagnosis of schizophrenia among increasing numbers of African Americans?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) - 5


The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA) and offers a common language and standard criteria for the classification of mental disorders. As of this publication, the DSM is now in its fifth edition, the DSM-5, published on May 18, 2013

That's a very important question. I argue extensively in my book that the purpose of my analysis is not to lay blame for individual racism, because I feel that such blame-games oversimplify what was going on. Many of the doctors at Ionia genuinely wanted to help their patients. I also talk to psychiatrists who worked on the DSM-II who told me that they were trying to do the best they could to produce scientific, objective diagnostic criteria.

At the same time, my Evidence shows how even the most Scientific Diagnostic Criteria can Reflect the Social Environments in which they are Produced, a Process I Discuss through the Language of Structural or Institutional Violence

This was certainly the case for the DSM-II. As I show, the manual's emphasis on hostility and aggression reflected a much-wider set of national conversations and anxieties about civil rights. The shifting frame surrounding schizophrenia had dire consequences for African American men held at the Ionia State Hospital during the civil-rights era. More broadly, my evidence also shows that growing numbers of research articles in professional journals used this language to cast schizophrenia as a disorder of racialized aggression.

In the worst cases, psychiatric authors conflated the schizophrenic symptoms of African American patients with the perceived schizophrenia of civil rights protests, particularly those organized by Black Power, the Black Panthers, the Nation of Islam, or other activist groups. Ultimately, new psychiatric definitions of schizophrenic illness in the 60s impacted persons of many different racial and ethnic backgrounds. Some patients became schizophrenic because of changes in diagnostic criteria rather than in their clinical symptoms. Others saw their diagnoses changed to depression, anxiety, or other conditions because they did not manifest hostility or aggression.

How did the psychiatric profession characterize schizophrenia before the first and second editions of the DSM?

Insanity has a long and fascinating history. Before the advent of what we call "modern psychiatry," conventional wisdom had it that specific actions and life events caused specific types of insanity. Paupers Lunacy was thought to result from habitual intemperance, poverty, and destitution, treated by a diet of wholesome digestible bread and milk porridge, along with occasional topical bleedings. Masturbatory Insanity came from onanistic self-corruption and led to a form of idiocy manifest by sallow skin, lusterless eyes, flabby muscles, loose stools, and, of course, cold and clammy hands. And Old Maid's Insanity was, as the name implied, the insanity of old maids.

Two Key figures Helped to Change the Course of How we Think about Insanity

Emil Kraepelin was foremost among a group of European clinicians who defined insanity not according to causes or symptoms, but according to course and prognosis.
In 1899, he coined the term dementia praecox to describe the "development of a peculiar simple condition of mental weakness occurring at a youthful age." 
And in 1911, Swiss psychiatrist Paul Eugen Bleuler argued that the underlying mechanism in praecox was a "loosening of associations," a process in which patients existed in the real world and at the same time turned away from reality ("autism") into the world of fantasy, wishes, fears, and symbols.

As an early proponent of Freudianism, Bleuler placed psychosis on a spectrum with neurosis as a developmental disorder with childhood origins. He maintained that the term dementia praecox should be replaced by a name that combined the Greek words for split (schizo) and mind (phrene). "I call dementia praecox ‘schizophrenia,' " he wrote, "because the ‘splitting' of the different psychic functions is one of its most important characteristics."

You make a powerful case for the way schizophrenia was transformed into a racialized disease at Michigan's Ionia State Hospital. To what extent can one extrapolate from that large psychiatric hospital broader trends across the country?

As a cultural historian and psychiatrist, I'm able to show how trends at Ionia reflect a series of larger cultural trends. One key literature that emerges in the 60s concerns the persistent race-based overdiagnosis of schizophrenia in African American men. 

For instance, in the 60s, National Institute of Mental Health studies found that "blacks have a 65% higher rate of schizophrenia than whites." 

In 1973, a series of studies in the Archives of General Psychiatry discovered that African-American patients were "significantly more likely" than white patients to receive diagnoses of schizophrenia, and "significantly less likely" than white patients to receive diagnoses for other mental illnesses such as depression or bipolar disorder. 

Throughout the 1980s and 90s, a host of articles from leading psychiatric and medical journals showed that doctors diagnosed the paranoid subtype of schizophrenia in African-American men five to seven times more often than in white men, and also more frequently than in other ethnic minority groups.

I also document in the book how associations between insanity and the civil rights movement played out extensively in American popular culture, and helped to shape the emergence of a much wider set of stigmatizations of schizophrenia—that it was an unduly hostile or violent disorder. I look closely at changing twentieth-century American assumptions about the race and temperament of schizophrenia through sources including American medical journals, newspapers, popular magazines, historically Black newspapers, studies of popular opinion, music lyrics, films, and civil-rights memoirs. I also reproduce unbelievable pharmaceutical advertisements that show angry black men protesting in the streets as ways of selling antipsychotic drugs.