Introduction
The age of racism is not yet over even though the Black Americans have claimed their rights a long time ago in the United States. Racial discrimination, race superiority, and race inferiority still exist in most sectors of the society. In the workplace, race and gender issues have been the major problems of employees as well as several firms, industries, and multinational corporations. The field of sociology has been studying the causes and effect of these racial implications and inconsistencies within some of the fields or sectors. According to most psychologists, the Theory of Evolution by Charles Darwin is consistent with the trends and basis of racial discrimination in the society. The concept of survival of the fittest suits the nature of racial inconsistencies and discrimination in the society (Horton, 2014).
Racial discrimination and inconsistencies could also be observed in the clinical diagnosis and diagnostic classification of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) released by the American Psychiatric Association (APA). Several experts have been investigating the reliability of the DSM clinical classification due to some of the racial inconsistencies and implications on Black Americans. One major reason for the inconsistencies and racial implications is that the American Psychiatric Association based the DSM mainly on Western ideals and psychology. The Western influence on psychology made the classification of mental disorder the basis of formulating the DSM categories and not on the causes of the disorders (Horton, 2014).
The objective of this research paper is to analyse how DSM was used in the racist manner and how it influence the Black American label on pathology and psychology. This research paper also opts to evaluate how these racial implications and inconsistencies affect the nature of psychology and the society of Black Americans.
Background on DSM-5
The Diagnostic and Statistical Manual of Mental Disorder (DSM) is a publication used in classifying mental disorders. It is initially published by the American Psychiatric Association (APA) in 1952. The DSM was developed from the census and statistics collected from the psychiatric hospitals and other institutions such as the United States Army (American Psychiatric Association, 2013). Other form of manual or publication used in the classification of the mental disorders includes the International Statistical Classification of Diseases and Related Health Problems (ICD). The DSM was revised through time based on the newly collected data and statistics from different studies. In the modern times, the DSM was on its fifth revision (DSM-5) and it was published on May 18, 2013 (American Psychiatric Association, 2013).
The DSM-5 is the latest update to the APA tool for classification of mental disorders. This manual is universally accepted as the main tool for the psychiatric diagnosis in the United States (Neighbors et al., 2003). The revisions made in the DSM are also considered as practically important since it does not only determine the classification of mental disorder but it also determines the treatment recommendations and payment for the health care providers based on the disorder classification (American Psychiatric Association, 2013). The current version of this manual including the previous versions has been helpful in providing treatment guidelines for various mental disorders as well as in classifying it. One of the main advantages of the establishment of DSM-5 is that it acts as the main basis for the psychologists and psychiatrists in handling people with mental disorders. However, there are also issues regarding the nature of the DSM.
The publication of the first edition of the DSM in 1952 was accompanied by several concerns. Most of the experts and psychiatrists suggest and argued that the DSM has vague guidelines in their criteria regarding clinical diagnosis of several mental disorders (Mukherjee et al., 1983). Since most of the criteria are based on statistics and understanding from current status of literature studies, the first edition of the DSM lacks many concepts and ideas regarding dealing with psychological disorders (Bell & Mehta, 1980).
With the release of DSM-II in 1968, it was able to remove the vague guidelines from the previous version (Horton, 2014). However, several experts observed highlighted that these manual have racial implications and inconsistencies within the guidelines or criteria set in the DSM. One major example of racial inconsistencies in the DSM is the diagnostic criteria for Schizophrenia among Black Americans. In order to address this racial inconsistencies issue, revisions must be done on the diagnostic criteria for Schizophrenia affecting Black Americans (Bell & Mehta, 1980).
DSM-5 Used in a Racist Manner
The DSM-5 faced an issue regarding racial discrimination due to the negative labelling of the Black American. Some of the studies suggested that there have been inconsistencies and mismatches between the local and national phenomenology of the mental disorders and the criteria used in the DSM-5 (Metzl, 2009). There are also certain specific cultural and race-related contexts which are found in the diagnosis or the classification of several anxiety disorders – indeed a form of racial inconsistencies. With these issues, most of the studies suggested that several revisions should be made in the DSM-5 in order to remove the race or ethnic related issues and implications so as to avoid the possibility of racism in the society (Bell & Mehta, 1980).
One of the main evidence that there is a misrepresentation in the clinical diagnosis of mental disorders is that Black Americans are over diagnosed with a certain type of disorder. There are more Black Americans diagnosed with Schizophrenia and there are more whites who are diagnosed with mood disorders. In general Schizophrenia is considered a more intense type of mental disorder (Mukherjee et al., 1983). People who are diagnosed with schizophrenia often lose their jobs and handle with more care than people who diagnosed with mood disorder. In this case, white people could acquire the advantage over the blacks when regards to employment.
This issue regarding racial discrimination and inconsistencies in the clinical diagnosis of the mental disorders is not a new problem. There have been sociologists who are interested in understanding several racial discrimination, implication, and inconsistencies within the criteria of the classification and clinical diagnosis of mental disorders. These sociologists have been focusing on extracting the racial implications that could be found in the guidelines of the DSM-5 and its other versions (Horton, 2014).
Most of the studies conducted in the 1980s suggested that there have been misrepresentation on clinical judgement in the diagnosis of several mental disorders. There are two main reasons why DSM-5 was considered as a tool for racism or racial discrimination (Metzl, 2009). The first main reason is that racial discrimination arises from the misinterpretation of existing diagnostic evidences. Most of the experts refer to the diagnosis of Schizophrenia as an “over-diagnosis” for Black Americans (Horton, 2014). On the other hand, they used the term “under-diagnosis” to describe the local phenomenology of the diagnosis of mood disorder in Black Americans. Several experts believed that the revisions in the DSM were based on a skewed statistics and could not reflect the true clinical diagnosis of several mental disorders.
One of the reasons why DSM-5 is considered a tool for racism is that racial discrimination is not included in symptoms for the diagnosis of some mental disorders. According to Hinton et al. (2010), racial discrimination could be a cause of post-traumatic stress disorder (PTSD). However, the DSM-5 does not recognize trauma which is based on race or ethnicity. It means the guidelines provided in the DSM-5 does not consider the fact that Black Americans or any other minority groups which experienced extreme trauma due to racism could be a cause of PTSD. In this case, it could be a reason for misdiagnosis and wrong clinical treatment of patients experiencing racial discrimination (Hinton et al., 2010).
Possible Reasons for Misdiagnosis
The second main reason is that misdiagnosis creates disagreements among the clinicians or psychiatrists. Even though some studies shows over-diagnosis and under-diagnosis of several mental disorders among Black Americans, clinicians who have used semi-structured instruments showed that there are no racial inconsistencies within the clinical diagnosis (Mukherjee et al., 1983). In general, misdiagnosis and disagreements among clinicians are due to their misuse of clinical uncertainties. The diagnosis of mental disorders relies on the reports coming from the patient itself. Clinical uncertainties should be used by the clinicians or psychiatrists in evaluation of several factors that could influence the patient’s reports such as cultural differences and racial stereotypes.
Inappropriate Use of Western Psychology (From Bipolar and Depressive Disorders)
Since the DSM-5 is mainly based on Western Psychology, it can be observed that the manual has racial implications and inconsistencies. Western psychology is considered by most of the sociologists and psychologists as Eurocentric and it revolves around individualistic approach in its major concepts (Landrum-Brown, 1990). In most cases, the Western psychology does not cover the appropriate coping strategies for Black Americans suffering from mental disorder.
Over-all, the DSM-5 does not cover all strategies or appropriate clinical approach in treating mental disorders among different racial cultures. One of the main reasons, as mentioned earlier in this paper, is that western psychology focuses on the classification of the mental disorder and not on the causes of these disorders. The use of Western psychology on the Black American community could create racial inconsistencies since it could not recognize the racial stereotypes of being black (Baker, 2001). Another reason is that the use of Western psychology could also influence the misdiagnosis of mental disorder due to the Eurocentric point of view.
The use of Western psychology could be observed in the criteria or guidelines of the DSM-5. In the DSM-5, the bipolar disorders are separated from the depressive disorders. There are links between schizophrenia, bipolar disorders, and depressive disorders (Baker, 2001). The DSM-5 classifies bipolar disorders between the schizophrenia and depressive disorder. In this case, it could be observed that the focus of the DSM-5 is the classification of the mental disorders. It could not be appropriately applied to Black American communities since it does not recognize some of the most important aspects of clinical diagnosis such as race and ethnicity (Horton, 2014). In addition, the DSM-5 guidelines for bipolar and depressive disorder lack recognition on the role of race and ethnicity for influencing mental disorders. In this case, the DSM-5 is mainly advantageous towards the whites since it could be easily applied to them. Consequently, Black Americans are at a disadvantage since they are not being recognized and generalized as a victim of the black experience (Baker, 2001).
According to studies, the use of western approach in the clinical diagnosis of mental disorder could result to racial discrimination among Black Americans (Baker, 2001). In the case of the bipolar and depressive disorder, the DSM-5 guidelines only focused on the individualistic approach in observing the symptoms. However, it does not include some factors such as the cause of these symptoms. Sometimes, the cause of these symptoms includes stress due to racial discrimination and racial stereotypes (Baker, 2001). If the clinician did not consider this as in the observation of the mental disorder, he or she could misdiagnose the patient.
Schizophrenia
Most of the studies suggest that large populations of the people in the United States who are diagnosed with schizophrenia are Black Americans. In the guidelines of the DSM-5 for the diagnosis of schizophrenia, several important symptoms must be present (Neighbors et al., 2003). These symptoms should be present for about several months in order to be diagnosed with schizophrenia. The major symptom for schizophrenia is hallucination. The effect of hallucination could be described as experiences which are like perceptions but have no external stimulus or actual occurrence. Other symptoms of schizophrenia as described in the DSM-5 include catatonic behaviour, unrelated response to questions, disorganized speech, frequent switching of topics, and grossly disorganized.
Another major symptom of schizophrenia as stated in the DSM-5 is delusion which could be described as fixed beliefs that could not be easily changed even if there are conflicting evidences. The misunderstanding between the referential delusions and persecutory delusions could be some of the causes of misdiagnosis of schizophrenia among Black Americans (Horton, 2014). Referential delusion refers to the type of delusion which could be described as a belief that the actions of some people are directed to an individual (Whaley, 2001). On the other hand, persecutory delusion refers to the type of delusion which could be described as a belief that a person is going to be harassed or violated (Vedantam, 2005).
These types of delusions could be possible reasons for the misdiagnosis of schizophrenia among Black Americans. The experiences of oppression and racism could result to these types of delusion among Black Americans (Neighbors et al., 1989). In some cases, these delusions are in fact a reality which could be a possible cause of misdiagnosis of clinician or psychiatrist. In addition, with the DSM-5 mainly based on Western psychology and principles, it could be subjected to error when diagnosing people from the Black American communities (Horton, 2014). Persecutory delusions should not be considered as a symptom of schizophrenia. Rather, it should be considered as the cause of the stress and other negative feelings which the Black Americans are experiencing (Whaley, 2001).
Some of the Black Americans are actually suffering from negative experiences such as oppression and racism. With this generalization, some of the clinicians view them as delusions which could be a sign or symptom of schizophrenia (Horton, 2014). The improper diagnosis of this mental disorder is a concrete proof that the DSM-5 is misused in a racist manner – by diagnosing an Black American patient of having schizophrenia when in fact the patient is suffering from oppression and racism (Strakowski et al., 1996).
In the guidelines set by the APA for the DSM-5, it clearly states that acknowledging the socioeconomic status of the patient is essential in the diagnosis of several mental disorders including schizophrenia. However, the DSM-5 lacks organized guidelines regarding the understanding of the cultural context and language used of the Black Americans (Lewis-Fernandez et al., 2009). Disorganized speech is one of the main symptoms of the schizophrenia as stated in the DSM-5 (Horton, 2014). However, clinicians should also remember that disorganized speech could also be due to differences in languages. Considering this situation, the DSM-5 did not acknowledge the Black American culture and linguistics and only focused on the Western ideologies or principles associated to psychology.
The over-diagnosis of schizophrenia among Black Americans in the United States could result to several functional consequences. Most of the studies suggest that the proportion of Black Americans who are diagnosed with schizophrenia is larger than the whites. In this case, the negative stigma about the mental disorder could be suffered by the Black Americans. Biases may arise due to improper diagnosis of patients due to cultural and race issues. Schizophrenia is often characterized as a mental disorder which impairs academic abilities and the capacity to work as an employee. Black Americans are overgeneralized and suffer the consequences of negative stigma about the mental disorder (Horton, 2014). With this issue at hand, the DSM-5 should be revised in order to acknowledge some of the factors that should be included. Moreover, it must be revised so as to provide a more impartial diagnosis for patients. Some of these factors that should be considered and included could help Black Americans to take benefit from the DSM-5 as much as the whites acquire.
Clinical Bias and Clinician Error
Several clinical diagnoses of mental disorders are not based on the interpretation of pure scientific methods. Pure scientific method is not always appropriate to the clinical diagnosis of some mental disorders listed in the DSM-5 such as the affective and non-affective disorders. In this case, the clinical diagnosis of these types of mental disorders is based on the judgement and interpretation of the clinician or psychiatrist (Horton, 2014). Several studies have shown that clinical diagnosis of mental disorders is commonly based on the interpretation of the clinician. These interpretations are based on the guidelines and criteria set by the APA in the DSM-5. In general, the clinicians or the psychiatrists have an important role in the diagnosis of the mental disorder with the use of the DSM-5 (Lewis-Fernandez et al., 2009).
Studies also suggested that there are two main reasons for the misdiagnosis of several mental disorders. These misdiagnoses could be due to the lack of understanding of the DSM-5 or the lack of adequate factors that should be considered within the DSM-5 (Landrum-Brown, 1990). The first reason for misdiagnosis is the lack of adherence of the DSM-5. Moreover, the second and the most striking factor is the racial bias among clinicians (Whaley & Hall, 2008).
Overlooking the cultural contexts of several important variables reported by the patient is part of the racial or clinician bias in the diagnosis of mental disorders. Some of the clinicians misinterpret some of the guidelines in the DSM-5 which could influence their clinical judgement and result to clinician bias. Misinterpretation of the mental disorder diagnosis is more common among Black Americans due to clinicians overlooking the cultural differences (Horton, 2014).
Clinicians should also consider the oppression and racism suffered by the Black Americans in order to avoid misdiagnosis. Since the DSM-5 is only based on the classification of mental disorders, it could not recognize some of the important factors such as the cultural norms. Cultural norms of the white should be considered as different kind to the cultural norms of the Black Americans. Lastly, the DSM-5 should also include sensitivity to the normative culture of the Black Americans in order to avoid cultural bias in the diagnosis of the mental disorders.
Interracial treatment and racial issues are not covered in the DSM-5. In addition, racial inconsistencies are still observable from the clinical diagnosis of mental disorders. These inconsistencies could be due to the misinterpretation or clinical bias of several clinicians and psychiatrists. However, it should also be remembered that these clinicians only based their judgement and interpretations from the DSM-5. In this case, DSM-5 could be considered as a tool for racial discrimination. There have been wrongful diagnoses of several mental disorders due to the lack of acknowledgement of the APA in their DSM-5 regarding cultural differences.
There are studies suggesting the racial inconsistencies among the whites and the Black Americans with regards to clinical diagnosis of mental disorders are an unconscious process (Lewis-Fernandez et al., 2009). It means, clinical bias becomes normal since most of the clinicians and psychiatrists are unconsciously not considering cultural contexts or norms. The DSM-5 has a major role in the acknowledgement of the cultural norms and contexts for the clinical diagnosis of several mental disorders or illnesses (Horton, 2014). The level of attention given to various races in the DSM-5 should consider equality in order to address the issue of biasness. Since the DSM-5 lacks information about cultural and racial differences among people which could be disadvantageous to Black Americans, revising the manual with the consideration of neutrality can eliminate the persisting problem.
Assessments of the psychiatrists are important in the diagnosis of patients with mental disorders. These assessments are evaluated using the guidelines set by the DSM-5. However, the DSM-5 lack assessment tools for racial and ethnic factors. According to Atdjian and Vega (2005), the cultural contexts are not included in the DSM-5. It means, racial factors are not considered in the evaluation of the patient with mental disorders by the psychiatrists. They also added that the DSM-5 should also be revised in order to help psychiatrists in understanding cultural contexts and avoid language and cultural barriers for patients and psychiatrists (Atdjian & Vega, 2005).
Conclusion
Racial discrimination and racial inconsistencies could still be observed in the modern times despite the fact that the Black Americans have gained the respect they deserved from several institutions. Racial inconsistencies could be observed in the clinical diagnosis of mental disorders through the use of the DSM-5 (Horton, 2014). The DSM-5 was created in order to set guidelines and criteria for the classification of mental disorders. However, the APA, which published the DSM-5 as well as the other versions, lacks acknowledgement for the cultural differences among people especially for the Black Americans. In order to resolve this issue and to properly help the users of the DSM-5, the manual must be revised accordingly while considering the issues at hand including racial biasness in diagnosis of mental disorders in order to fully understand such cases with impartiality as a major consideration.
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