At What Point Is Racism a Presentation of Psychosis? A Case Study

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Racism is a concept of distinct beliefs, emotions, attitudes, stereotypes, and ideologies which differentiates based on a perception of superiority and inferiority.¹ It is not usually considered a psychotic symptom and therefore it is not often considered in the diagnosis of schizophrenia. Typically, early signs of schizophrenia consist of negative symptoms, such as social withdrawal, decreased capacity for conversation, and neglecting of activities of daily living. Development of negative symptoms may precede the emergence of positive symptoms, such as hallucinations and delusions, by several years, in what is often called the prodromal phase of schizophrenia.

Delusions are defined as fixed, false, and idiosyncratic beliefs. In addition, the ideas that a person is exposed to during the prodromal phase of the illness can influence the delusions they later develop.² Regardless, initial treatment remains largely the same: the initiation and titration of an antipsychotic medication, with regular assessments for reduction of symptom burden as well as improvement of insight. Delusions are notoriously hard to treat, often requiring prolonged treatment with incomplete resolution of symptoms. As insight improves, patients may become candidates for cognitive behavioral therapy adapted for psychosis, in which rational challenges of psychotic symptoms may be attempted.³ However, the goal of treatment remains the reduction of symptom burden rather than the complete resolution of the delusions.

We present the case of a young woman who developed symptoms of psychosis including delusions, affective flattening, and alogia, with insidious onset over the period of 1 year. The patient’s delusions were centered around racist and sexist beliefs specifically towards African Americans and women. She also exhibited hostile behaviors towards individuals from these demographics, including refusal to cooperate with them, use of degrading language, and repeated remarks indicating homicidal ideations. The patient’s delusional beliefs appear to have developed in the context of a larger, nation-wide conversation regarding attitudes towards ethnicity and gender.

Little research has been done on the development of racist and sexist beliefs as a manifestation of a developing psychotic illness. Thus, this case study serves as a valuable exploration of the similarities and differences between more typical prejudicial beliefs versus prejudicial beliefs developed as manifestations of psychosis. This discussion is particularly relevant at this time given the prominence of race and gender issues in modern culture. The prominence of these topics suggests we may see more cases of psychosis involving similar delusions in the near future.

Case Study

“Vishwa,” age 31, is a woman of Indian origin who presented to the emergency department (ED) in a medium-sized midwestern city with her mother and father for evaluation of homicidal ideations and bizarre thoughts. Vishwa had no significant prior psychiatric or medical history. Vishwa’s parents reported that for the past 3 years, their daughter was working in a large city in a southern state as a consultant after completing an engineering degree from a top ranked US university followed by a master’s degree from a top ranked US business school. Her long-term relationship ended 6 months prior to presentation and her employment ended around 3 weeks prior. The circumstances surrounding both events remain unclear, with Vishwa indicating that her employment ended due to her workplace not recognizing her talent. She had moved back in with her parents in their home in the Midwest after the end of her employment.

Vishwa’s parents reported that 3 weeks prior, she made statements that women are inferior and that African men and women are slaves. Vishwa’s parents insist that such ideas have never been espoused in their home, family, or community. Her mother noted that Vishwa had previously commented on the introduction of diversity, equity, and inclusion initiatives in her workplace in the past year and thought Vishwa developed these beliefs about women and African Americans in response. Her father hypothesized that Vishwa had a negative experience with women or Black individuals while working at her last job, possibly having been passed over for a promotion in light of her comments about her unrecognized talent. Her parents also reported that, in the past 6 months, she had been more withdrawn and blunted.

A first break psychosis work-up was unremarkable. In the ED, she refused to speak with or accept treatment from African American or female staff. She expressed wanting African Americans and women killed due to their inferiority, referencing Hitler in a reverential manner for the mass death of inferior individuals that he was able to bring about. She did not wish to engage in the killing personally, remarking that Black individuals and women are “not attractive enough targets.” She used derogatory and dehumanizing terms such as “rapist,” “baboon,” and “whore.” She emphasized that she would only speak to and cooperate with “white enough men,” which included Caucasian men.

There were minimal symptoms present suggestive of depression, mania, anxiety, posttraumatic stress, or substance use. Vishwa did not have a history of paranoia or hallucinations. However, throughout the course of her acute illness, her expression of prejudicial delusions was constant and consistent, with no significant amenability to rational challenges. In defense of her delusions, Vishwa appealed to concepts from genetics. When the logic of her arguments was challenged, she became simpler in her assertions and did not engage. She did not appear to be responding to internal stimuli. She did not have pervasive disorganized speech or behavior except for when she intermittently spoke in short, agrammatical phrases to communicate demands to staff. She did exhibit blunting of affect consistently.

Vishwa was initiated on risperidone 0.5 mg twice daily for 3 days. Her family had concerns for risk of tardive dyskinesia while on risperidone, therefore, with her family’s input, the medication was changed to olanzapine 5 mg nightly and titrated up to 10 mg twice daily. She continued her racist and sexist commentary, such as “females and Black males are unclean.” She disrespectfully commanded Black males, telling them to bring her the dinner tray, have the bathroom cleaned, clip her fingernails, saying “go ahead slave.” She was verbally abusive towards women, calling them “heinous white woman,” and “dirty female rapist.”

The delusions and behaviors did not improve on olanzapine; thus, Vishwa was cross titrated onto paliperidone. Significant improvement in her interactions with staff were noted once she was taking paliperidone 9 mg. She was willing to speak with her clinician, a Caucasian female, after refusing to do so since the beginning of the admission. Her thought process became more logical with regards to why she referred to individuals as “rapists.” Departing from the standard definition, she explained her use of the term referred to those she deemed responsible for causing her mental and emotional abuse.

After reaching a target dose of paliperidone 12 mg daily, Vishwa became more future oriented and appropriate in her interactions. She began inquiring about her treatment plan and was motivated for discharge. She spoke to staff members respectfully and no longer referred to anyone by derogatory terms. Vishwa stated that she did not recall her behaviors throughout admission, and she was surprised to hear of how she spoke with staff members, noting that she does not think about individuals based on race and gender and would never speak to others in such a manner. However, she continued to have a blunted affect, and certain bizarre beliefs persisted, such as her insistence that her mother is “sinless” and that her father is “white,” despite her family being of an Indian ethnic background.

Discussion

Vishwa’s delusions centered on race and gender. She used derogatory terms and expressed homicidal ideations with no fear of consequence or concern of her actions. This change in behavior at the age of 31 in conjunction with the development of negative symptoms suggests a diagnosis of schizophrenia. Her symptoms did not respond to olanzapine 20 mg daily. As an adequate dose of paliperidone was reached, she had complete resolutions of prejudicial delusions and improvement of negative symptoms, but she continued to have bizarre delusions regarding her parents.

The way Vishwa expressed her delusional and bizarre thinking was unique; she was absolute and unyielding in her thinking when it came to African Americans and women. She remained fixated on her disdain even in situations where passive cooperation would have benefited her personally. She persisted in her beliefs and maintained her superiority despite her and her family members falling outside of the demographics that she deemed to be acceptable. Her commitment to these beliefs despite their contradictions with her own personal and professional experiences begs the question: what was driving the specific content of Vishwa’s delusional beliefs?

Of note, Vishwa’s delusions focused on minorities that have been prominent in recent discussions in the media. Her delusions regarding race and gender may seem to align with extremist views that tend to surface in response to efforts to promote racial and gender diversity in society, paralleling non-idiosyncratic beliefs held by many individuals without a diagnosed mental illness. While the full clinical picture of Vishwa’s behaviors suggest she was exhibiting delusions related to psychotic illness, the prevalence of similar beliefs in the public makes it unclear how much of her espoused beliefs she was sympathetic to prior to developing psychosis versus the beliefs being a result of exposure during the period of heightened vulnerability as she was developing psychosis.

Racial biases have been discussed through the lens of psychiatric illness and psychotherapy by researchers going as far back as after World War II. Three cases demonstrated examples of prejudicial ideations against ethnic minorities with relevance to classically recognized psychiatric illness.⁴ One case described a patient who developed prejudicial beliefs as a type of negative alteration in cognition and mood, suggestive of posttraumatic stress disorder (PTSD). The prejudicial beliefs diminished with behavioral modification therapy of the trauma-related symptoms. Another case discussed a patient who underwent a similar trauma with development of PTSD, but instead he held related prejudicial beliefs prior to undergoing the inciting traumatic experience and, in contrast, these beliefs did not diminish with similar treatment. The third case described a scenario where outgroup bias resulted in significant impairment of social functioning, and the prejudicial behaviors also did not respond to psychotherapy. These cases suggest it may be prudent to distinguish new onset prejudicial ideations from preexisting ideations as a relevant prognostic factor.

In the aforementioned 3 cases, prejudicial ideations were delineated by a therapist in the course of the patients receiving treatment for previously diagnosed psychiatric disorders. There have been proposals for new psychiatric disorders which would identify prejudicial ideations as constitutive of psychopathology, typically in the family of personality and anxiety disorders rather than psychotic disorders. Such classifications would be expected to have major cultural implications, as highlighted by Pouissant, who proposed the concept of “extreme racism” as a type of delusional disorder in response to a period of several publicized racially motivated killings.⁵ He wished to oppose the legitimization of such behaviors amongst the public by pathologizing the paranoid thinking which motivated many of these killings.

On the other hand, the ramifications of considering racial prejudice within the realm of psychiatric disorders must be considered.⁶ Firstly, to consider a collection of symptoms as constituting a disorder, there is the general standard that it must cause clinically significant suffering and/or incapacity. In Vishwa’s case, there is a clear case for incapacity. However, suffering is a much more subjective criterion that may be controversial to establish in many cases of racial prejudice. Nonetheless, efforts are being made to develop tools to measure such suffering, such as the Outgroup Hostility Scale.⁷ Additionally, one must consider the effect of such a classification on the criminal justice system, given the disparate way we address hate crimes vs crimes related to manifestations of psychiatric illness.

Efforts to target racial prejudice have been explored in several research studies. Different interventions to target these biases have been studied including implicit bias training, diversity and inclusion training, cognitive behavioral therapy, and exposure therapy. The general trends show reduction in expression of racial bias and implicit gender bias through trainings.^8-11 However, when outcome measures are untethered to more direct measures of suffering or incapacity, it is unclear to what degree these interventions can be genuinely promoting well-being vs successfully training individuals to express more socially acceptable sentiments. However, in cases where expression of nonsocially acceptable sentiments causes significant friction between individuals and the social systems they interface with, a case can be made that decreases of such expressions is indeed therapeutic.

Other factors relevant to the treatment of racial prejudice include cognitive functioning. Studies show individuals with higher cognitive abilities such as Vishwa may not respond to treatments designed to reduce prejudicial beliefs with the same reliability as the general populace. This may be understood as being due to a greater ability to create and maintain rationales supporting their preexisting beliefs.¹² Also documented are studies demonstrating there is a resistance to changing falsely held beliefs despite being presented contradicting evidence, suggesting that such beliefs are prone to a sort of inertia which resists correction.¹³

Concluding Thoughts

In summary, this case highlights a patient’s delusion of racism that was treated appropriately with antipsychotic medication leading to resolution of symptoms. It is important to realize that individuals express racist thoughts and views but would not be considered to have delusions. In instances where, for example, patients admitted to the psychiatric unit make racist remarks, the treatment plan does not shift to ensure that the patient no longer is racist. In this case, Vishwa’s parents say that the racist remarks were new, warranting further evaluation into these symptoms. Vishwa’s appropriate response to the medication treatment also supports that the racism was a part of her psychosis, and not an inherent part of her racial biases.

Dr Arif and Dr Manjunath are third-year psychiatry residents at the University of Illinois College of Medicine in Peoria. Ms Muppavarapu is a fourth-year medical student at the University of Illinois College of Medicine in Peoria with an interest in psychiatry. Dr Lancia is a professor in the Department of Psychiatry and Behavioral Medicine at the University of Illinois College of Medicine in Peoria.

References

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