The Intersection Between Psychiatric Misdiagnoses of Schizophrenia and anti-Black Racism

By Salma Metwally

A split mind

Before delving into this topic, it would be useful and arguably necessary to provide a diagnostic summary of schizophrenia and its more unfamiliar criteria, since understanding these and their context is crucial for providing context for the topic we’re discussing today.

The word “schizophrenia” originates from ancient Greek and roughly translates to “split mind,” indicating a split or break from objective reality. This pertains more specifically to schizophrenia spectrum illnesses such as schizophrenia or schizoaffective disorder, but not other psychotic illnesses like the primary mood disorders. Schizophrenia is characterized by chronic or recurrent psychosis, that includes positive symptoms such as hallucinations (false perceptions of any of the five senses), delusions (firm beliefs that are not grounded in reality), disorganized or incoherent thinking and speech, but can also often include odd or unexplainable behavior, catatonic symptoms (disturbances in movement and response to one’s environment), and negative symptoms such as diminished emotional expression and lack of motivation. In this case, positive and negative symptoms refer to the addition or removal of an experience or behavior in a person.47

Drapetomania: justice becomes insanity

In 1851, Samuel Cartwright, a psychologist in the southern states, claimed to have discovered an explanation for why slaves desired freedom from their masters: a mental illness called “drapetomania” that was unique to Black individuals. At the time, especially in the South, slaveowners were genuinely perplexed by slaves’ desires to be free and independent. Although seeing the absurdity of slavery is comically easy now, it wasn’t as easy before the Civil War, which is why so many slaveowners turned to psychology for an explanation. To them, slaves were meant to be subserving property that did as it was told without question or resistance.

Slavery had historically been the norm throughout human civilization, and the beliefs used to justify enslavement were seen as scientifically valid and indisputable facts. It was commonly believed that Black people were put on this earth solely for the sake of willingly serving Whites in exchange for shelter and clothing. Cartwright believed that Black people had smaller brains and overdeveloped nervous systems that made them desire servile and subservient positions to their White counterparts. Coincidentally, the word “drapetomania” also originates from the Greek language, roughly translating to “crazy runaway slave.”

Cartwright proposed toe amputation or “whipping the devil out of the slaves” as foolproof methods to “cure” this mental illness, but also as preventative measures. He believed that drapetomania presented itself when god’s “natural order” was disturbed and slavemasters treated their slaves as equals. Should a slave appear sulky and withdrawn, this would indicate a plan to escape.44, 45 Cartwright also went on to invent a mental illness called “dysaesthesia aethiopica,” which characterized freed slaves as lazy and incompetent, which he claimed was much more prevalent in Black communities as opposed to isolated Black individuals living alone or in primarily white regions. This may also explain why depression is often underdiagnosed or undertreated in Black communities and written off as laziness or incompetence, mirroring the 19th-century idea of dysaesthesia aethiopica.44, 49

The effects of these damaging and incorrect labels can still be observed today. Mental health and illness are much more stigmatized in the Black community, which has also resulted in the underdiagnosis of mood disorders in Black populations. Although this may be surprising to most, severe mood states such as depression, mania, and mixed states (a combination of both depressive and manic symptoms occurring simultaneously), when they go untreated for long enough, can (and quite often do) result in psychotic symptoms. It’s estimated that roughly 18% of patients with major depressive disorder (MDD), 20% of patients with bipolar disorder type II, and 50% of patients with bipolar disorder type I have suffered from psychotic symptoms. However, when assessing Black patients, many non-Black psychiatrists often assume that schizophrenia or substance use disorders are the primary issue, despite the presence of a mood disorder better explaining those symptoms.43, 46, 50, 51, 56

When schizophrenia became a Black man’s disease

It was in the 1960s, during the Civil Rights Movement, when the cultural notions around schizophrenia shifted, from the benign and pitiful illness that afflicted helpless and overworked White women to the terrifying disease of the enraged and dangerous Black man’s mind. With the publication of the second edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) came the transformation of the image of the White woman and the Black man. The White woman was now agitated or depressed and the Black man was no longer antisocial.53

The fight for civil rights turned the Black man into a paranoid schizophrenic. And although our current DSM no longer differentiates between the different types of schizophrenia, the Black man was always seen as paranoid. Never disorganized. Never catatonic. Never undifferentiated.48, 53 The Black man needed to be restrained and contained. Even during the 2010s, numerous studies found that Black and male patients with the same symptoms as White and female patients were more likely to be diagnosed with a schizophrenia spectrum illness as opposed to an affective (mood) disorder; instead of being diagnosed with autism spectrum disorder, PTSD, or major depressive disorder, Black patients are more likely to be diagnosed with bipolar disorder or schizophrenia. Additionally, instead of being diagnosed with ADHD, Black kids are also usually diagnosed with oppositional defiance disorder.41

During the 1960s, different medications were marketed specifically for the “angry Black male” who experienced delusions of victimization and persecution that caused him to “irrationally” attack the establishment. The most prominent neuroleptic (antipsychotic) to be marketed at this time was Haldol, a typical antipsychotic that was particularly infamous for its extreme sedating effects and significant role in causing tardive dyskinesia (an antipsychotic-induced movement disorder that occurs more commonly with older antipsychotics).

Even now, different drugs carry different connotations in the field of psychiatry. Drugs like Haldol and Thorazine (older antipsychotics) are associated with the non-compliant and aggressive male, while drugs like Seroquel and Latuda (newer antipsychotics) are associated with the confused woman or the frightened adolescent. In psychiatry, every antipsychotic subconsciously conjures up a certain image of a certain psychiatric patient. Haldol happens to conjure up the image of the screaming and violent male patient in restraints.55 Physicians often prescribe extremely high doses of typical (first-generation) antipsychotics to Black men, despite the fact that Black Americans are twice as likely to develop tardive dyskinesia as opposed to White Americans. Why? Because those same antipsychotics are subconsciously associated with Black men due to decades of institutional and medical racism, gaslighting, and propaganda.40, 42, 46, 58

Healthy paranoia and cultural differences

Years of medical mistreatment have understandably led the Black community to be very suspicious of White authority figures.40 And while this is obviously a result of generations of racial trauma, many Black psychiatrists believe that this “healthy paranoia” towards the medical system is a legitimate clinical concern, especially since a significant number of patients with schizophrenia experience persecutory delusions surrounding the belief of malevolent psychiatrists or poisoned medications; Black patients have every right to be mistrustful.41 Not only are they more likely to be incarcerated for the same symptoms that White patients would instead be hospitalized for, but Black individuals are also more likely to be involuntarily sectioned or treated with hostility by both law enforcement and medical professionals.49, 52, 57

A very common symptom of schizophrenia is tangential, disorganized, or incoherent speech. Cultural idioms like “It’s raining cats and dogs!” could very easily be misinterpreted as disorganized speech in non-English-speaking countries. And yet, because idioms like these are used among the general White population, the concern surrounding psychosis and incoherent thinking for White patients virtually disappears among most psychiatrists. However, on the other hand, when a White psychiatrist doesn’t understand African-American Vernacular English or cultural idioms of the Black community, simple, harmless statements can be interpreted as aggressive, nonsensical, concerning, or as evidence of a psychotic state.54

About the Author

Salma Metwally is a high school student from California. She enjoys researching political affairs, history, psychiatry, and neuroscience. In her free time, she likes to crochet and do Taekwondo. A fun fact about her is that she speaks four languages.

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