BROOKE GLADSTONE: Schizophrenia has appeared in every edition of the DSM, but a constant presence doesn't mean a fixed definition. Over the years, the entry for schizophrenia has changed, partly because brain imaging technology has allowed researchers and psychiatrists to peer inside the patients’ brains and trace the physiological trail of mental illness. But University of Michigan psychiatrist Jonathan Metzl, who we just heard from briefly, says imaging is not the only factor shaping our evolving view of schizophrenia. It’s also shaped by our changing perspective on gender, race and violence. In his new book, The Protest Psychosis, Metzl argues that schizophrenia looked very different in the first half of the 20th century, typified in the 1948 film, The Snake Pit, in which Olivia de Havilland plays a middle-class woman who just three days after her wedding hears voices, sees hallucinations and cannot recognize her own husband.

[CLIP]

OLIVIA de HAVILLAND AS VIRGINIA CUNNINGHAM: I have no husband.

LEO GENN AS DR MARK KIK: You haven't? I thought you were married.

OLIVIA de HAVILLAND AS VIRGINIA CUNNINGHAM: I am married.

LEO GENN AS DR MARK KIK: If you’re married, doesn’t that mean that you have a husband?

MARK STEVENS AS ROBERT CUNNINGHAM: Virginia darling, look at me! Don’t you know who I am? I’m Robert! Virginia!

[END CLIP]

BROOKE GLADSTONE: She undergoes psychotherapy from an all-knowing analyst and is reunited with her husband in the end. Jonathan Metzl says this is how we used to see schizophrenia, a disease of docility affecting white women.

JONATHAN METZL: And then all of a sudden you see the assumption about who got schizophrenia and how they acted changed very dramatically in the 1960s, in the context of civil rights. And that’s where you see this shift from an illness of docility to one of hostility. And then, all of a sudden, you see popular media and films replete with representations of African-American men who have gone crazy because they are, in different ways, participating in civil rights protests, for example, the movie Shock Corridor in 1963, which was another asylum film.

BROOKE GLADSTONE: Let's talk about Shock Corridor. The main schizophrenic character wasn't an Olivia de Havilland housewife but an African-American former civil rights protester named Trent, who apparently was driven insane by his thwarted attempts to desegregate America?

JONATHAN METZL: Basically the pressure of trying to change Southern white civilization in the movie literally drives him insane, to the point where he becomes a violent racist.

[SOUNDTRACK UP AND UNDER And in the film’s key scene, he actually starts a race riot on the ward.

[CLIP]

HARI RHODES AS TRENT: [SHOUTS] Hallelujah, there’s one! Let's get that black boy before he marries my daughter! Hallelujah!

[CROWD YELLS/END CLIP]

JONATHAN METZL: Starting in the early 1960s, you see increasing numbers of African-American men show up in depictions of schizophrenia. And the Shock Corridor is one excellent example of that, but there are many other examples from the media.

BROOKE GLADSTONE: Some of them involve advertising.

JONATHAN METZL: Correct. Yeah, one of the main ads that I use, it’s an ad for an antipsychotic medication called Haldol, ad it shows an African-American man in the streets, literally shaking his fist, and the text says, “Assaultive and belligerent? Cooperation begins with Haldol.” And, again, this was a radical shift, because ads in the 1950s for anti-schizophrenia medications showed docile white women, so all of a sudden in the 1960s and 1970s you see these transformations.

BROOKE GLADSTONE: And it was in 1968 that this evolution in the image of schizophrenia seems to have been solidified with the publication of the DSM-II. How did it redefine it?

JONATHAN METZL: There’s new language in the definition of paranoid schizophrenia. They specifically add the terms “aggression,” “hostility” and “projection.” But what I show in the book is that that language, at the time, in the 1960s, was disproportionately used to diagnose black men.

BROOKE GLADSTONE: How do you show that?

JONATHAN METZL: When these terms, “aggression,” “hostility” and “projection” were added to the DSM and appeared in psychiatric publications, eight out of ten articles, roughly, talked about black male subjects with schizophrenia. We applied a similar analysis to medical charts and again showed how that language purportedly was used to talk about mental illness, but unconsciously was a way of diagnosing race, as well.

BROOKE GLADSTONE: We've mentioned ads and movies. I'm just wondering – it’s the chicken and the egg question – do the media reflect the changing definitions of the psychiatric community, or are they pushing them forward?

JONATHAN METZL: Well, it does create a chicken and the egg question. In a lot of cases, the changing media representations predated the changing psychiatric ones.

BROOKE GLADSTONE: Mmm.

JONATHAN METZL: In other words, you could see terms like “aggression” or “hostility” or these representations of people, like Trent in Shock Corridor showing up a good five, six, seven years before that change happened in the DSM. The DSM is a cultural document, and it reflects its cultural environment as much as anything else.

BROOKE GLADSTONE: How do you think schizophrenia should be defined? Do you think that “hostility” should be in there? Do you think “split personality” should be in there?

[OVERLAPPING VOICES]

JONATHAN METZL: I would certainly say that I agree with the DSM right now. There is nothing about hostility or aggression or projection in the DSM. Those terms were, thankfully, taken out of the DSM. At the same time, there is research that consistently shows that schizophrenia is over-diagnosed in African-American men, and so there is a particular racial valence around this diagnosis. And I think that paying attention to the ways in which schizophrenia intersects with certain racial stereotypes is very important for understanding cultural attitudes about this illness. It should be defined in terms of symptoms, such as delusions, hallucinations, paranoia - debilitating symptoms that can ruin people’s lives.

BROOKE GLADSTONE: Jonathan Metzl is a professor at the University of Michigan and author of The Protest Psychosis: How Schizophrenia Became a Black Disease. Jonathan, thank you very much.

JONATHAN METZL: Thank you so much.

[THEME MUSIC UP AND UNDER]