New-Onset Racism or Psychosis?

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Racism 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 neglect of daily living activities. 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.

The ideas that a person is exposed to during the prodromal phase can influence the later delusions.¹ Regardless, initial treatment remains largely the same: the initiation and titration of antipsychotic medication, with regular assessments for reduction of symptom burden as well as improvement of insight. Delusions are notoriously difficult 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.² However, the goal of treatment remains the reduction of symptom burden rather than the complete resolution of the delusions.

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 an exploration of the similarities and differences between more typical prejudicial beliefs vs prejudicial beliefs developed as manifestations of psychosis. It is particularly relevant given the prominence of race and gender issues in cultural and medical discussions. The prominence of these topics suggests we may see more cases of psychosis involving similar delusions in the near future.

Case Study

“Vishwa” is a 31-year-old Indian woman who presented to the emergency department (ED) in a midwestern city 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 had been 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 had ended approximately 3 weeks prior. The circumstances surrounding both events remained 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 Black 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 Black individuals 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 she had become more withdrawn and blunted in the past 6 months.

A first-break psychosis workup was unremarkable. In the ED, she refused to speak with or accept treatment from Black or female staff. She expressed wanting Black individuals and women killed due to their inferiority, and 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 White men.

There were minimal symptoms present suggestive of depression, mania, anxiety, posttraumatic stress disorder (PTSD), 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 about the risk of tardive dyskinesia while she was 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, and clip her fingernails, saying, “Go ahead, slave.” She was verbally abusive toward women, using the phrases “heinous 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 was noted once she was taking paliperidone 9 mg. She was willing to speak with her clinician, a White woman, after refusing to do so since the beginning of the admission. Her thought process became more logical about 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 was “sinless” and that her father was “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 for her actions. This change in behavior in a 31-year-old woman 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 Black individuals 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 raises the question: What was driving the specific content of Vishwa’s delusional beliefs?

Notably, Vishwa’s delusions focused on members of minorities that have been prominent in recent discussions in the media. Her delusions regarding race and gender seemed to align with extremist views that tend to surface in response to efforts to promote racial and gender diversity in society, paralleling nonidiosyncratic beliefs held by many individuals without a diagnosed mental illness. Although the full clinical picture of Vishwa’s behaviors suggests she was exhibiting delusions related to psychotic illness, the prevalence of similar beliefs in the public makes it unclear how many of her espoused beliefs she was sympathetic to prior to developing psychosis vs 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 the 1940s, after World War II. Three cases demonstrated examples of prejudicial ideations against ethnic minorities with relevance to classically recognized psychiatric illness.³ One case described a patient who developed prejudicial beliefs as a type of negative alteration in cognition and mood, suggestive of 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 patient’s 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 cases, prejudicial ideations were delineated by therapists in the course of the patients receiving treatment for previously diagnosed psychiatric disorders.

There have been proposals for new psychiatric disorders that 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.⁴ He wished to oppose the legitimization of such behaviors by pathologizing the paranoid thinking that motivated many of these killings.

On the other hand, the ramifications of considering racial prejudice within the realm of psychiatric disorders must be considered.⁵ 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 was 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.⁶ 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 a reduction in expression of racial bias and implicit gender bias through training.^7-10 However, when outcome measures are untethered to more direct measures of suffering or incapacity, it is unclear to what degree these interventions are 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 in 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.¹¹ Also documented are studies demonstrating there is resistance to changing falsely held beliefs despite being presented with contradicting evidence, suggesting that such beliefs are prone to a sort of inertia that resists correction.¹²

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 of these symptoms. Vishwa’s appropriate response to the medication treatment also supports that 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.

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