The 48-year-old man turned down a job because he feared that 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 even avoided 12-step meetings out of fear he might encounter a gay person.
"He had a fixed delusion about the world," said Sondra E. Solomon, a psychologist at the University of Vermont 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 that 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 that 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 C. 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!' "
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 systematic study.
Darrel A. Regier, director of research at the psychiatric association, said he supports research into whether pathological bias is a disorder. But he said the jury is out on 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 the 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 suffered from 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, 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 launch 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 young 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 F. 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," he said. "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 antipsychotic 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 antipsychotics does work to reduce these prejudices."
Amid a profusion of recent studies into the nature of prejudice, researchers have found that biases are very common. Almost everyone harbors what might be termed "ordinary prejudice," the research indicates.
Anthony Greenwald, a psychologist at the University of Washington in Seattle, and Mahzarin R. Banaji, a psychologist at Harvard, developed tests for such biases. By measuring the speed with which people make mental associations, the psychologists found that biases affect even those who actively resist them.
"When things are more strongly paired in our minds, we can respond to them more quickly," Banaji said. "Large numbers of Americans cannot as swiftly make the association between 'black' and 'good' as they can between 'white' and 'good.' "
Similarly, psychologist Margo Monteith at the University of Kentucky in Lexington found that people can have prejudices against groups they know nothing about. She administered a test in which volunteers, under time pressure, had to associate a series of words with either "America" or a fictitious country she called "Marisat."
Volunteers more easily associated Marisat with such words as "poison," "death" and "evil," while associating America with "sunrise," "paradise" and "loyal."
"A large part of our self-esteem derives from our group membership," Monteith said. "To the extent we can feel better about our group relative to other groups, we can feel good about ourselves. It's likely a built-in mechanism."
If biases are so common, many doctors ask, can racism really be a mental illness?
"I don't think racism is a mental illness, and that's because 100 percent of people are racist," said Paul J. Fink, a former president of the American Psychiatric Association. "If you have a diagnostic category that fits 100 percent of people, it's not a diagnostic category."
But Poussaint said there is a difference between ordinary prejudice and pathological bias -- the same distinction that psychiatrists make between sadness and depression. All people experience sadness, anxiety and fear, but extreme, disabling forms of these emotions are called disorders.
While people with ordinary prejudice try very hard to conceal their biases, Solomon said, her homophobic patient had no embarrassment about his attitude toward gays. Dunbar said people with pathological prejudice often lack filtering capabilities. As a result, he said, they face problems at work and home.
"Everyone is inculcated with stereotypes and biases with cultural issues, but some individuals not only hold beliefs that are very rigid, but they are part of a psychological problem," Dunbar said.
The psychologist said he has helped such patients with talk therapy, which encourages patients to question the basis for their beliefs, and by steering them toward medications such as antipsychotics.
The woman with the bias against Jews did not overcome her prejudice, Dunbar said, but she learned to control her fear response in social settings. The patient with hostility against African Americans realized his beliefs were "stupid."
Solomon discovered she was most effective dealing with the homophobic man when she was nonjudgmental. When he claimed there were more gays and lesbians than ever before, she presented him with data showing there was no such shift.
At those times, she reported in a case study, the patient would say, "I know, I know." He would recognize that he was not being logical, but then get angry and return to the same patterns of obsession. Solomon did not identify the man because of patient confidentiality.
Standing in the central yard of the maximum-security California State Prison with inmates exercising around her, Chaiken explained how she distinguished pathological bias from ordinary prejudice: A prisoner who belonged to a gang with racist views might express such views to fit in with his gang, but if he continues "yelling racial slurs, assaulting others when it's clear there is no benefit" after he leaves the gang, the behavior was no longer "adaptive."
Prison officials declined to identify inmates who had been treated, or make them available for interviews.
Chicago psychiatrist Bell 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 at 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."
The psychiatrists said their profession has neglected the issue: "One solution would be to encourage research that seeks to delineate the validity and reliability of racism as a symptom and to investigate the possibility of including it in some diagnostic criteria sets in future editions of DSM."
Edward Dunbar has proposed guidelines for a diagnosis.
Darrel A. Regier also supports further research.