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Race, Culture, and Diagnosis of Psychosis
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Hello and welcome. Thank you for joining the Third National Conference on Advancing Early Psychosis Care in the United States, presented by SMI Advisor. We are pleased to present today's session, Race, Culture, and Diagnosis of Psychosis. Well, welcome. My name is Dr. Deidre Anglin. I'm an associate professor of psychology in the doctoral clinical psychology program at the City College of the City University of New York. I have postdoctoral research training in psychiatric epidemiology from Columbia University's Mailman School of Public Health. I lead several projects and mentor students in my clinical and social epidemiology lab designed to identify social determinants of psychosis risk in populations of color. I've published several papers focused on race, racism, and psychosis, and the stigma of mental health service utilization in Black and Asian populations. I'm very excited to be presenting today. I have no financial relationships with commercial interests or conflicts of interest to report. So today, what I'm really hoping that you end with are these three learning objectives. First, I'm really hoping that I can explain how historical sociopolitical movements in the United States have contributed to the over-diagnosis of schizophrenia in Black people. Then moving forward, identify three ways mental health clinicians tend to experience challenges diagnosing people of color accurately. And last, describe how social factors connected to racial discrimination contribute to vulnerability for psychotic experiences in Black and Latinx people. So for today, over the period of this course, first I will discuss the historical role of racism in the psychiatric diagnosis of African Americans, giving a brief overview of some key moments that really highlight how racism has played a role in psychiatry. Describe explanations for racial disparities in the diagnosis of schizophrenia. And then moving forward, explain racial disparities in psychotic experiences in some of the literature there. Discuss ways racial discrimination and trauma could influence the expression of psychotic experiences. And lastly, identify factors that could improve clinical assessment of psychosis in racially minoritized groups. So objective one, history of racism in psychiatry and diagnostic practices. Let's talk about that. And so before we begin thinking about, you know, sort of history of racism in psychiatry, I like to really define race in a way that speaks to my understanding of it and Guess's definition really does. It's a socially constructed taxonomic stratification of power based on proximity to whiteness, with individuals of African descent being the most distal category for the purpose really of maintaining a culture of white supremacy. And so when we think about race, I mean, I think many folks in psychiatry and in many fields understand that it is socially constructed and where you fall in that hierarchy might differ depending on your context. And in the United States, one of the real centering ways in which this taxonomy has been constructed is around how close are you to whiteness and whiteness is also a construct, frankly. And so thinking about why would race and racism matter in a medical field, it speaks to the reality that this social taxonomy is a stratification of power. And as we know, institutions hold power, right? And so I want you to keep this definition in mind as we think about the findings and the results that I'll be presenting today, because it highlights that it isn't about a particular person or a particular race in a particular way. It's really about this power stratification. And a lot of the work that I'll be presenting will be on populations of African descent, in part because this is the taxonomy. Okay. So I'm going to go a little bit ways back in thinking about, well, how has racism impacted diagnosing in terms of medicine? And going back as far as times of slavery, these were used as a form of social control. So drop it to mania was actually a diagnosis given to African slaves during that time. And it was identified as sort of a form of mental illness diagnosed as the uncontrollable urge to escape. So in some ways, if someone was fighting to be free, they were diagnosed, right? And labeled because there was a power structure that had an incentive to keep African slaves, sort of not wanting to escape and keep keeping them disenfranchised. And so this was used as a way of describing a behavior that didn't fit with what the power structure and the status quo of that time desired. And so it even went so far, you know, as to describe the African slaves who had this should be kept in a submissive state and treated like children with care, kindness, attention, and humanity to prevent and cure them from running away. You know, I put this on here because I see it as sort of like ridiculous, right? But at the same time, this was taken very seriously at that time, you know, so the power, sociopolitical structure of that time, this was absolutely something that was status quo. And so it's important to keep this in mind, because even moving forward, you know, much more further in time, Metzl did a really interesting qualitative study that was published in the book, The Protest Psychosis. I highly recommend it if you haven't read it. I think more folks know about this now. I've been talking about this for a long time, and folks mostly didn't read this book, but now I think people are more interested. But what, you know, he and colleagues did is they did research at Ionia State Hospital for the Criminally Insane in Michigan. And they looked at records over spanning several decades, from the 1930s, all the way to the 1970s. And they analyzed the progress notes, they even interviewed some of the attendings who were there at that time who are, you know, now older. And they basically wanted to get a sense of how descriptions of patients, you know, sort of the makeup of the patient body, how that changed over time, kind of like a, taking a bird's eye view of something. And it really describes how schizophrenia became racialized during the Civil Rights Movement. And so initially, you know, a lot of the words sort of earlier in the 1930s, 1940s, 1950s, words associated with schizophrenia were, you know, withdrawn, you know, patients with schizophrenia, confused, docile, they sort of, let's help them kind of, you know, they need support type of, you know, language. And then in the 1960s, they saw a shift in the kinds of ways people with schizophrenia were described, threatening, aggressive, paranoid, and dangerous. And so, I mean, did the disorder just change over time? Or did something else change, right? And so thinking about it, they looked at Black and white patients with schizophrenia, and they looked and saw just how differently these groups on average were described in these clinician, you know, clinical records. And some of the terminology even linked participation in civil rights protests with violent schizophrenic symptoms, quote, in Black populations in ways perceived as threatening to the white majority. And so even in this state hospital psychiatric ward, there was this sort of political peace in there. And, you know, civil rights, as you know, 1960s, there was a lot of protesting, there was a lot of fighting for freedom among Black people, as well as others who were allies. And so it just really, it just, I think about parallels now in terms of the reckoning that's happening right now around racism, and sort of being attuned to how we think about how we describe patients, right, and patients who might be considered deviant, right, and why they consider deviant. So it just, this is really meant to highlight how our diagnosing and our understanding of and perception of clinical phenomenology is not devoid of the sociopolitical movement at the time. And this was such a powerful illustration of that. So in thinking about the DSM-5, and just like the diagnosis of schizophrenia, I thought it would be good to kind of go through it and think there and go in, I'll get to parts that I think make it challenging in terms of accurate diagnosing of populations of color. But first, you know, two or more of the following, each present for a significant portion of time during a one month period, or less if successfully treated, at least one of these must be delusions, which are sort of odd, rigid thoughts that don't really fit with the majority of the reality of persons, hallucinations, sort of altered perceptions, disorganized speech, and coherent speech, this sort of thought disordered, sort of not making sense, not linear thinking, grossly disorganized or catatonic behavior. And then there's negative symptoms, things speaking to diminished emotional expression or abolition. So these are the different kinds of symptoms, categories that constitute schizophrenia. And then for a significant portion of the time, since the onset level of functioning in one or more major areas, such as your work, interpersonal life, self care, especially, is markedly below the level achieved prior to the onset of these symptoms. And so this is sort of, you know, the conceptualization of schizophrenia that we all sort of mostly adhere to. And so there've been racial disparities, right, in the diagnosis of schizophrenia, which I think is, you know, very well known at this point. And so what are some of the explanations that are in the literature for these racial disparities? Let's go through that objective. So one of the, you know, so you could sort of say, oh, well, there's just racial difference, you know, that different groups are more or less likely to have schizophrenia. But a large, you know, so Black and sometimes Latinx individuals are overrepresented in the patient population with psychosis. And this has been something that has been found repeatedly across decades. But keeping in mind the sort of political part, right, but this is just what the literature empirically has shown. And so recent meta-analysis show that Black individuals were 2.4 times more likely to receive a diagnosis of schizophrenia than White individuals. And this meta-analysis nicely reviewed and incorporated a lot of the studies. I was very familiar with Bill Lawson's work in inpatient state hospitals, Strakowski's work at the University of Cincinnati, Minsky's work in a large outpatient healthcare system in New Jersey, back then it was UMDNJ, large VA databases, and other inpatient hospitals. And so I sort of list a lot of these different kinds of places, right, because this disparity has been found across multiple different kinds of patient settings. But again, it's patient clinical treatment samples. And recently, which I think probably has a little bit less of some of the biases and looking at clinical hospital settings is Bresnahan and Mickey Bresnahan's group out of Columbia, they looked at the Kaiser Permanente birth cohort study. And they found this two to three-fold increase among African Americans compared to White Americans. And this was a birth cohort study. Again, it's a one health insurance panel. So that was something that was suggestive of, okay, maybe this isn't just like a clinical population bias. So again, thinking about sort of some of these sample selection biases, a lot of the epidemiologic community-based studies in the U.S. generally don't find significant differences in psychosis prevalence between Black and White Americans, or they find that any difference is explained by SES indicators. And so these are some of the earlier national comorbidity studies and the epidemiologic catchment area studies. They didn't necessarily find this, you know, really big difference. But again, in the U.S., the way our epidemiologic samples are, the methods used, we don't always have the best estimates of clinical psychosis, right? And so there's that caveat. So it's kind of left this picture of, right, okay, patient populations, there's this overrepresentation of Black and sometimes Latinx patients in the national epidemiologic samples. We don't find this difference, but we also don't really find a lot of people with clinical psychosis. So it's hard to say the one is, you know, but again, there's something discrepancy there. And so one of the things that has been highlighted going back to that DSM-5 schizophrenia diagnosis is there was a, there's a Part D here, and I'll read it. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either no major depressive or manic episodes have occurred concurrently with the active phase symptoms, or if mood episodes have occurred during active phase symptoms, they've been present for a minority of the total duration of the active and residual periods of the illness. And so I highlight this part here because this is where a lot of the literature has kind of looked to see, well, what might be going on in terms of this higher prevalence of clinical treated sample diagnosis of schizophrenia in Black and sometimes Latinx patients. And it's this understanding of, well, where's the mood in this? Is the mood a minority of the clinical presentation? Is it like a bigger picture? And so that was a big part of one of the sets of explanations in this understanding that African-Americans maybe may not be more likely to have schizophrenia because there is this misdiagnosis that is occurring. And so one of the large, I think a pretty large body of research has really looked at this to see, well, is this happening? And several studies have identified that that mood component, that missing of affective symptoms in Black patients or Black folks who come in with a clinical presentation, there's this sort of lower probability of seeing, well, there's some depression here, or this is mania. And I remember experiencing this as an intern where I had a patient who came in, he definitely had some psychosis, but he seemed like a lot of mania, a lot of grandiosity and emotional expansiveness. But he was just getting schizophrenia. It was sort of like, that's what he is, that's what he has, that's what he has. And so there was a reluctance to think of, well, maybe there's a bipolar presentation here with psychotic features. Anyway, in the end, he ended up having a more bipolar presentation. When he was given a mood stabilizer, it really helped him incredibly. So I've even seen this in my own work as a clinician, clinical trainee, and different studies have shown this, even as recently as 2018, GARA in their group at Rutgers, they looked at community outpatient clinics and they found that there's this under-emphasis on depression. So I'll get a little bit more specific into those under-emphasizing affective symptoms studies in Black individuals. So Strakowski and colleagues in a large span of time out of the University of Cincinnati, they did a lot of work really trying to understand the diagnostic process and racial dynamics and other cultural dynamics that influence the diagnostic process. And they found that Black individuals were more likely than white were more likely than white individuals to receive a diagnosis of schizophrenia and less likely to receive a diagnosis of psychotic depression, even though the rate of current depressive episodes between the two samples were very similar. So there was like sort of studies showing that both racially grouped samples, the mean level of depression is quite the same, yet one is more likely to get a schizophrenia diagnosis. And again, like I was saying, GARA and their group found African-American patients diagnosed with schizophrenia were more likely to screen positive for major depression than white patients diagnosed with schizophrenia. And so there's sort of this discrepancy, what it might mean, you could kind of argue different things, but there's definitely some kind of discrepancy in the degree to which Black participants come in with depression and then end up getting some kind of affective diagnosis versus white patients that come in. And so again, under not only depression, but mania, Strakowski and their group looked and sampled 100 patients with psychotic mania, and they just kind of compared the admitting clinical diagnosis to a more gold standard, if you will, research diagnosis using SCID and PANS and other kinds of structured instruments. And, you know, they wanted to kind of compare whether you might find a discrepancy in this clinician diagnosis, business as usual, admitting diagnosis, and the more structured, rigorous research SCID diagnosis. And so they found no difference in the research SCID diagnoses between African-Americans and Caucasians with psychotic mania, but upon admission, the clinical sort of business as usual diagnosis, African-Americans were more likely to receive that clinical diagnosis, a clinical diagnosis other than bipolar or schizoaffective disorder. So that included even things like, I think, psychosis NOS and schizophrenia. So again, there's this kind of discrepancy racially around the degree to which affective symptoms, including mania, are adhered to, if you will, in the clinical encounter. So that was one set of the explanations for this relationship between, you know, African-American status and schizophrenia and it being misdiagnosis. Another set of explanations sort of kind of spoke to the clinical encounter and not just clinicians not sort of seeing or giving as much weight to affective symptoms, but there are these sort of cultural factors or just really, you know, being a group that's been oppressed in this country factors, speaking about like this wariness. And so cultural mistrust, you know, which might argue, is it really cultural? But it's basically a normative, healthy level of wariness that is more common among African-Americans, but also other oppressed cultural groups in response to centuries of racism and oppression in society. And centuries of racism and oppression that definitely manifests through institutions, right, through research. I mean, everyone knows of Tuskegee, but there are several other kinds of egregious misuses of institution and health systems to exploit African-Americans and other marginalized oppressed groups. And so this normal, healthy level of wariness is not necessarily pathological, but it's associated with depression in African-Americans. Arthur Whaley did a lot of work in this area and found that it was associated with depression. It's associated with fewer disclosing statements in cross-race dyads to white counselors, and it can be misinterpreted as pathological guardness and paranoia, as opposed to like a more healthy wariness in light of your circumstances. And Whaley did a study where he found that cultural mistrust is actually a separate factor from pathological paranoia. And he looked at this in African-American patients with schizophrenia, and he saw that the two are not just one and the same, and they're not like on some continuum. They're separate things. And one is a more pathological paranoia, and one is just a more sort of a wariness. And so the thought is if folks are coming in, you can imagine African-American patient coming in very depressed, dealing with racism, discrimination, different issues going on, and is now the only person they're seeing is this white counselor who is now he or she's more guarded. You could kind of see how this might influence the diagnostic encounter, the clinical encounter. And so lastly, another set of explanations on the sort of misdiagnosis explanation area for the disparity is, you know, studies have actually found that interviewers, just their perceived honesty, how honest do they see their patients who are coming in? And they found that it was lower for African-Americans. And this explained the disparity between white and Black patients and the diagnosis of schizophrenia. And so things like perceived honesty, you know, there's a lot that goes into the clinical encounter. And all of these kinds of things have definitely influenced the diagnostic process in a way that contributes to this disparity, racial disparity in the diagnosis of psychosis and schizophrenia in particular. And so does that explain all of the variants? Probably not, you know, but I think that is a really big factor that attenuates the degree to which folks feel like, oh, there's definitely this disparity in racial disparity in the diagnosis of schizophrenia and psychosis. So, you know, we've been talking about, you know, schizophrenia and the diagnosis and clinical settings. And I've become a lot more interested in psychotic experiences and thinking about psychosis as a spectrum and racial disparities more broadly. And so are there, you know, disparities, racial and ethnic disparities in the psychosis spectrum? So before I sort of go into that, I think it's good to think about this extended psychosis phenotype, which I think over the past few decades has received more and more attention and the understanding that it's not sort of like either you're clinically psychotic or not, but that there's a spectrum of experiences and symptoms ranging from more normal to more frank clinical psychotic disorder. And, you know, these kinds of subclinical experiences, they're, you know, more prevalent in the population than I think we used to think of it. And these experiences can be more symptoms when there's a little bit of distress associated with the altered experience or the thinking that's odd or the thought you can't get out of your head, you know, or the, you know, you sort of feel like you had like saw something, you know, like you're having it, but it's maybe more frequent and not necessarily a clinical disorder yet, but that median prevalence of that is like 8% in the population with a range. And so the idea is that folks can fall along this spectrum. And then obviously what I think we're most familiar with is like having like a clinical disorder, a diagnosable DSM type of disorder where the symptoms are much more persistent and severe and in a way where it's impairing your functioning more. And then there's this psychosis risk syndrome, which has received a lot of attention in terms of thinking of folks who are, they have these symptoms and experiences, you know, some things that you hear about more, like there's a whisper. It's not a full voice that you're hearing, but it's like, you feel like there's this whisper or you feel like there's visually something is changing right before your eyes, you know, but you realize it might not be real. There's some insights still there, but you're really at a high risk of sort of going into the blue circle. And so this psychosis risk syndrome is something that has received a lot of attention in terms of thinking about, maybe we can help folks, help folks not necessarily go into the blue circle, you know? So that's just sort of like a really brief overview of this extended psychosis phenotype. And I'm really interested in it more broadly and thinking about, are there racial disparities at, like across the spectrum? And that lends itself less to like whether clinicians are misdiagnosing people or have biases or, you know, but like these are self-reported experiences and symptoms. Are people of color, Black, Latinx folks in particular, are they more likely to report these kinds of experiences and symptoms? And so the epidemiology of these experiences and symptoms has been really helped in understanding it by the large psychiatric epidemiology surveys, comprehensive surveys coming out of University of Michigan, where they're oversampled and really gotten full samples across different populations of color. And so Cohen and Marino did a study where they looked at the large epi studies and looked at the prevalence of endorsing at least one lifetime psychotic symptom. And you can see here, 9.7% in white Americans, 9.6% in Asian Americans, and 13.6% in Latinx and 15.3% in Black Americans. And so there was a racial disparity, even here at this, you know, psychotic symptom level. And so some of the work in the Philadelphia Developmental Cohort studies, which are really rich cohort studies starting from early, have looked at the prevalence of attenuated psychotic symptoms. Again, these are not severe, they're like altered perceptions, not necessarily full-blown hallucinations. And they looked at this in a US-based representative cohort of youth, and the prevalence was estimated to be 12.9%. And so looking at racial group differences in this cohort, they found that non-white American youth had a 1.68 greater odds of being in this psychosis spectrum in terms of these attenuated psychotic symptoms. And so this in particular here is not necessarily about misdiagnosis, but it is still important in thinking about what these psychotic experience and symptoms might be consequential of, you know, in terms of why they might be more elevated in groups of color. So these symptoms, you know, while they're transitory in most people where they'll come and then they'll go and they won't necessarily stick, they're more common in people suffering from an anxiety or depressive disorder, right? So the prevalence is even higher among folks who have anxiety and depressive disorders. And the presence of these symptoms is associated with greater severity, more morbidity, poor prognosis among those with these common mental disorders. And so even though they're not necessarily schizophrenia, they are sort of indicators of a more problematic, more morbid, you know, more challenging course, even if you have another common mental disorder, like an anxiety or depressive disorder. And so I think they really deserve attention and thinking about like what, you know, what's the ideology of them. And so one of the things that I've thought a lot about in a lot of the studies in Europe have focused on like the social environment and these psychotic experiences and thinking about how they could be related to that. And so my fourth objective here is to really describe the ways racial discrimination in particular and trauma can influence the expression of psychotic experiences. So here, you know, I sort of highlight several studies that have really, you know, started to look at the role of racial discrimination in psychotic experiences in the United States. I think a lot of the research prior has really come out of the UK and the Netherlands, but there's been much more emphasis, I think, the past couple of decades in the United States. And so major discriminatory events, you know, not getting hired, you know, not being able to get credit, you know, sort of major, you know, issues with police, that was related to psychotic experiences among Black Americans and nationally representative sample. And here, you know, I did a study looking at racial discrimination and young people of color who reported these psychotic experiences and racial discrimination was related to that. And it wasn't just the paranoia, suspiciousness types of psychotic experiences, because that was sort of what I was wondering, is it just, is this a healthy paranoia type, you know, a cultural mistrust issue. But it was really across the board of psychotic symptoms. And then even in thinking of more clinical sample, perceived discrimination was related to conversion to psychosis for those at that clinical high risk period, that like small box of folks who are having these kinds of symptoms in a much more like worsening way, who are at higher risk for being, you know, who are at higher risk for being in that little blue circle, having a clinical psychotic disorder. Early traumatic experiences and perceived discrimination was related to conversion, folks who ended up in that blue circle. And so this is, was also looked at across different multiple ethnic groups, like whether perceived discrimination was related to psychotic experiences, not just in Black Americans, it was also found in Asian and Latin Americans. So, you know, this is some of the research that is really sort of building a picture where racial discrimination is like, we know it's a problem, like it's been related to depression, it's been related to anxiety, it's been related to a lot of mental health outcomes, but it's also related to the extended psychosis phenotype. And so, in terms of, you know, thinking about what these psychotic experiences could mean, or what could be influencing the expression of them, you know, in addition to racial discrimination, you know, thinking about dissociation, trauma induced dissociation, and can that be mistaken for a more psychotic process? And so, within the context of trauma and depression, altered perceptions, which is sort of a terminology for an idiom of distress, common in Latinx communities, can be attributed to psychotic processes. And Roberta Fernandez has done a lot of work in this area. And, you know, I've found that these altered perceptions, right, actually dissociative experiences that are adapted on this exchange. So, there's a way in which this kind of process of dealing with trauma and stress could be sort of mistaken for something more of a like psychotic, like type of process. And that's something to kind of keep in mind in thinking about what might influence, you know, someone endorsing psychotic experiences. Trauma induced dissociation was actually a study that I did actually explain the relationship between trauma and psychotic experiences in Black and Latinx adults. And so, there was a lot of folks who experienced accumulation of traumatic life events. And my young adult sample and this dissociation really explained that relationship between trauma and psychotic experiences. And so, you know, thinking about psychotic experiences and the spectrum, Black and Latinx individuals exposed to trauma may be at higher risk of exhibiting psychotic experiences because of dissociative experiences linked to trauma and stress, you know. And so, that might be something that, you know, we could look at more research trying to understand what contributes to these psychotic experiences. It might be something connected to trauma and trying to cope with, you know, accumulation of trauma and stress. And some folks, Carter and others, have really conceptualized forms of racial discrimination as kind of like a race-based kind of trauma. You know, it doesn't feel as far-fetched now. I mean, when people were talking about this 10 years ago, it was like, racism is not trauma, you know. But thinking about recent this year, I mean, the, you know, things that people have been exposed to now in terms of George Floyd and Breonna Taylor, you know, sort of more heightened, it's not so hard to imagine how racial discrimination and racism could be traumatic in a way. And so, you know, are Black and Latinx folks at higher risk for these, like, psychotic experiences because of the trying to deal with trauma? It's something that I'm, you know, very interested in, and I think more work is happening in that area. And so, another sort of point I want to bring up in terms of thinking about these psychotic experiences and how we measure them, thinking about the neighborhood and neighborhood crime and suspiciousness that's not pathological, some, there's risk for potential biases in the measurement of the psychosis risk syndrome that folks have found and psychotic symptoms in neighborhoods with high levels of crime. And so, if you're in a neighborhood with a high level of crime, there's a certain level of vigilance that needs to be maintained, which is not pathological, it's adaptive in certain ways to help you keep you safe. And so, are we, we need to be careful in how we measure that kind of suspiciousness element of the psychosis risk syndrome. So, studies, Wilson and Vargas and colleagues, they found neighborhood crime only correlated with the attenuated psychotic symptoms specific to suspiciousness. And so, that kind of, you know, you're sort of thinking about how we measure that. Are we capturing some of that, like, mistrust or just like vigilance in terms of the context? And so, this is something else to be mindful of in the diagnosis and assessment of the extended psychosis phenotype, is the degree to which context and where your patients are living and where they're coming from and what they're managing, to what degree is what you're seeing kind of adaptive in that environment. Even though it might be stressful and, you know, sort of need support, it's about really like sort of the interpretation. And so, thinking about the context is important in how we conceptualize and understand the phenomenology that's, you know, sort of coming into the room. So, again, like I was saying, increased suspiciousness and hypervigilance of people in high crime areas may be erroneously labeled as pathological in standard measures of psychosis risk in the absence of this contextual consideration and sensitivity. And so, when thinking about how we assess, it's really important to think about context and in a more specific way and be sensitive to that. At the same time, it's important not to just dismiss the possibility that the same stress dictated by these neighborhood factors that result in the hypervigilance might in and of itself lead to greater risk for psychosis. And so, it's really important to be nuanced and curious and flexible because, you know, you can't just say, oh, you're in a high crime neighborhood. So, okay, right? It's just a matter of really thinking about how that is impacting the person's presentation, but also acknowledging that that's a stressor. Okay. So, now I'm sort of moving to my last objective here, where let's identify factors that could improve clinical assessment of psychosis in racially minoritized groups. And I hope so far I've sort of identified some areas that we should be sort of mindful of in terms of the degree to which the person has trauma and is experiencing dissociation and the sort of context in which they live in their neighborhood and also your own kind of potential biases, right? Some of these factors are things that really I think being more mindful of will improve our assessment of psychosis in racially minoritized groups who have to deal with racial discrimination. So some of the studies that I've done have looked at, you know, sort of thinking about this use the prodromal questionnaire which is a self-report questionnaire that I like because it only not only has items that capture thoughts, feelings, experiences that fall in that extended psychosis phenotype, especially the attenuated psychosis risk syndrome part of that phenotype. But for every response that you endorse, you have to circle the word distress. So you have to indicate whether or not this has bothered you. And of course, you're instructed to not include experiences while using alcohol, drugs, or medication. So here's just some example items. And this is Rachel Lowey's measure which has been adapted, translated, and validated and used in different contexts. But here are just some of the example items. I've been distracted by noises or other people talking. The passage of time has felt unnaturally faster or slower than usual. I have had difficulty organizing my thoughts or finding the right words. When I looked at a person or at myself in a mirror, I've seen the face change right before my eyes. I've heard things that people couldn't hear, like voices of people whispering or talking. And so these items, you know, any one item isn't going to necessarily be indicative of, you know, sort of a challenge within the spectrum. But the more items you endorse, and the more items you endorse as, like, this is bothering me, the more at risk you are for having a more, sort of, a more challenging clinical picture in terms of the psychosis spectrum. And so the positive subscale has been validated against the structured interview for prodromal syndromes, which is a, you know, very labor-intensive diagnostic interview to try to capture people who are really at this risky phase. And again, I think the goal has been to sort of, can we improve prognosis or even maybe even prevent, you know, the transition or conversion to clinical psychosis? That's sort of, I think, part of the goal, but also for folks who experience these experiences, how can we help them, you know, help alleviate some of their distress? Okay, so I gave this measure along with other self-report measures to a large, non-treatment-seeking sample of young folks of color, majority folks of color, immigrants, first and second generation immigrant, and really trying to understand social context as it relates to endorsing these kinds of items that are in the extended psychosis phenotype. And there were a sample, you know, we had a small clinical reappraisal of a small sample of folks in the study who endorsed a lot of items and endorsed them as distressing. And so we looked at followed up 26 of them and interviewed them with a structured interview for prodromal syndromes and the SCID and global social and role functioning. And so there were 15 high scores of this on PQ, that prodromal questionnaire, 15 high scores. So they, you know, scored like eight or more of those items as like distressing. And then we looked at a random sample of low scores. And so I wanted to really understand a little more in depth of folks, because folks, we didn't find anyone who actually had clinical high risk syndrome, you know, where they were on the cusp of like just about to, you know, sort of on the cusp of having like a clinical psychotic episode. But we did find that folks who scored high, you know, there was a portion that didn't have a diagnosis, a SCID diagnosis. There was a portion that had a mood disorder, you know, when looking at the SCID. So like a generalized anxiety disorder, a major depressive, I'm sorry, major depressive disorder. There was one who had an anxiety disorder, other disorders, and then there was a small amount that had multiple disorders. And so I think it just sort of highlights something that has been looked at in the literature, reported in the literature quite a bit is that these psychotic experiences, they can go along with more common mental disorders, but create a more problematic potentially course. And so one of the things we're doing now is really taking a look into some of the descriptions of some of these young people who report a high number of these psychotic experiences. And in one case example, I'm going to present today, highlights really the role of trauma and dissociation in the endorsement of these psychotic experiences. So this was a 22-year-old Black cisgender female who had a parental history of schizophrenia and bipolar disorder. So I think her paternal history was schizophrenia and maternal bipolar disorder. She had a history of sexual abuse by a distant relative when she was, I think around 11 or 12. She had a prior history of cannabis use with the age of onset around 15, moderate alcohol use, not currently at the time of the interview. And she was currently in psychotherapy. And so her case really stands out to me because she has like several risk factors for psychosis, right, that have been identified in the literature from trauma to cannabis use to sort of an earlier age of onset to family, you know, loading family history of mental illness and schizophrenia in particular. And so she came up as not at clinical high risk in the SIPS interview, but some of what she reported, you know, you could sort of see how she would endorse a self-report inventory of, endorse positive on a self-report inventory of psychotic experiences. She reported feeling foggy all of the time. And that was exacerbated when she was smoking cannabis and she, she spoke a lot about this fog, you know, so she endorsed 14 positive PQ symptoms, her high, she had a high score on the structured interview for progenitor syndromes on the unusual thought content subdomains. And that was really the only one that was high. But again, like I said, she didn't meet criteria, but she did have this sort of unusual thought content elevation. She reported dissociative experience quite a bit in her interview, and she described it as like a brain fog. And so when asked on the SIPS, do familiar people or surroundings ever seem strange, she indicated if my brain fog is worse, my anxiety is worse. There's a component of unreality. Things feel a little more 2D. And so there was a way in which there was a connection between this fog and this sort of component of unreality. So you can kind of see the connection there. When asked on the SIPS, have you ever had the thought that you might not actually exist? You may not really exist. She indicated yes. And sometimes it makes me like dissociate a bit. She described the existential thought and brain fog as really, really terrifying, like an out of it feeling. And she described moments trying to cross the street where she found herself so confused, just standing there, not sure where she was. And then car started honking, you know. And so I sort of give this example as a person who you could totally see how they would have some psychotic experiences and that sort of feel like they're not, things are not really real because they're not, they're not attached. She's really disassociated with herself in a way. And when she, she couldn't really talk about the sexual abuse because she was quite dissociated from it. And it was her way of adapting. She was also high, you know, she was also doing fairly well in school. She was very insightful, but, you know, I think of someone like her, how can we be more supportive to her in a way? Because it's clear that these are things that are terrifying in a way, but they're connected to likely her trauma and her way of dealing with it, dissociation. So, so I kind of want to just take a little bit of time and go through just some conclusions and take home points. So psychosis, it really includes a spectrum of experiences and symptoms with increasing degrees of dysfunction that could be a component of many different disorders. You know, I think it's a dimension that can be like an indicator of more problematic course of other disorders. I mean, it's obviously also, you know, psychotic experiences and symptoms can increase risk for, again, like a more clinical psychotic disorder. But I think that, you know, it's really important to understand these experiences and symptoms at the subclinical level, because they can really exacerbate or be an indication of previous, more problematic social environments and potentially even trauma and dissociation. Psychotic experiences are significantly impacted and shaped by social context, especially structural racism in neighborhoods and cultural context. And so in thinking about being in an environment, being in a social context that is, you know, sort of repeatedly invalidating you in your existence and your, you know, sort of your ability to feel like fully whole and worthy, you know, and thinking about how structural racism can impact multiple levels, individual, social, neighborhood, that these kinds of social stressors and environmental insults may really be a significant risk factor for psychotic experiences, which then can set a person up for a more problematic mental health trajectory. And so it's really important to think about social context and thinking about the, you know, extended psychosis phenotype. Racism shapes the lives of people of color and the clinical encounter, you know, and so I think there's more and more acknowledgement of that now, but it's always been the case. It's not necessarily people are walking around people of color like, yes, racism shapes my life, you know, but it shapes it in so many ways, because that is how one of the ways that the social taxonomy of, particularly in the U.S., is really dictated in large part by the structural racism historically. And so if you think of the beginning of the presentation, it's not like this is starting now, right? And so how do we have more of an acknowledgement of that in our work with people of color? And they may not come in saying racism affects me, but like how might it be really impacting their, you know, their lives, their presentation, you know? And so one of the things that I know Compton and Shem have talked a lot about is, you know, thinking about social determinants of mental health and thinking about, I think racism is an important determinant. So ask yourself, you know, how does discrimination affect your patients and how does that contribute to their clinical picture? You know, it's not a simple question, but even just asking it, you know, is an important piece, because it's acknowledging a particularly important social factor, especially in this kind of context. In a different context, maybe it will be a different factor, right? I mean, and I think that's important to keep in mind, but in a U.S. context, the way our system has been shaped historically, race and racism is a big part of that. Another question, and I guess I'm speaking to the clinicians in the room, right? What information are you not hearing because of your socially dominant identities, right? And I think in addition to what you're hearing, what are you not hearing? And it's kind of hard to think about it that way, but I even think about that as a, you know, a Black woman when I'm sort of, you know, mentoring, I'm sort of thinking, how am I, and what I bring in the room, visibly anyway, right? How is that potentially, you know, shaping what I'm hearing and not hearing? And so it's important, I think, to keep that in mind and thinking about working cross-culturally, you know, across different social locations, and particularly ones that are visible, but, you know, can't assume things about social location identities that are not visible. This presentation today was about race, you know, and racism more focused, but there are other social locations that we know are quite important in thinking about how that impacts the clinical encounter. Gender, what are we assuming about people's gender? Are we assuming folks are cisgender? You know, like things like that, sexual orientation, you know, and so I think we tend to focus more on like things that are more visible, but I think there are other elements that are quite important to keep in mind. Okay, take-home points, especially for clinicians. So, subtle racial microaggressions can really impede proper communication and effectiveness with patients and impede the development of the therapeutic alliance, especially in cross-racial diets. And so there's definitely research that has really looked at this, especially in the counseling psychology literature, and have identified the ways that we microaggress in that clinical room, the thing, the way, you know, the way we ask questions, assumptions that we make in our questions. And so these kinds of things can really impede open communication, which then impedes the diagnostic process. And so I think and so I think that's another important piece to keep in mind, especially in cross-racial diets. So, cultural humility is talked about a lot more now, but it's really like, you know, being culturally humble acknowledges that you are not impervious to your socialization in this country. Like you're not like a steel frame that all of those preconceived notions and stereotypes and biases and the way you've been brought up, that's just not going to come in your clinical work. It's how can you kind of have the opposite approach where you are sort of like, clearly it is, let me be clear, you know, let me sort of be aware and conscious and curious and conscious and curious about how. So the more aware you are and the more humble you are, the more your ability, when it leaks into the therapeutic dyad, which it likely will, your attunement will help guide the process of dealing with it explicitly in the therapeutic relationship. And so it's sort of not like I would never do X, Y, and Z. It's like, well, let me be open to when I do, because I likely may. And it won't be something egregious, right? It could be something subtle, you know, just in terms of assumptions you might make about your clients. Cultural meaning making systems are brought to the interaction by each participant or multiple participants. And so therapists and patients, like a lot of times we think of, well, what is the cultural background of the patient? What's their social context? What, you know, what is their racial identity, right? Well, what is yours as the therapist? I think that's also quite important to be mindful of. What is your racial identity and where are you in your understanding of your social locations? You know, some of us have been brought up in ways as youngsters where, you know, how's that shaping your openness to dealing with what a patient is bringing in, okay? And, you know, silence around race or discrimination really may shut down open communication on a topic relevant to your patient's life. And so the more open you are about it, actually, I think the more meat you'll get as you're working with folks, because you'll be capturing more aspects of that person's day-to-day life in trying to understand them and in trying to better help them. So hopefully by the end, you'll see, you see where I stand, like it's important to be really open to discussing these issues that can be challenging. So thank you. This is the bibliography. So many, so much wonderful literature in this area. I'm sure I've missed several more, but I think that looking at race, racism, and culture and our diagnosis of psychosis is really critical. Thank you for your attention.
Video Summary
In this video, Dr. Deidre Anglin, an associate professor of psychology, discusses the intersection of race, culture, and the diagnosis of psychosis. She explores how historical sociopolitical movements in the United States have contributed to the overdiagnosis of schizophrenia in black individuals. She then identifies three challenges that mental health clinicians tend to experience when diagnosing people of color accurately. These challenges include misdiagnosing affective symptoms, experiencing cultural mistrust, and perceiving patients of color as less honest. Dr. Anglin also highlights how social factors connected to racial discrimination contribute to vulnerability for psychotic experiences in black and Latinx people. She discusses how racism has shaped psychiatric diagnoses throughout history, highlighting how African slaves were diagnosed with mental illnesses like "drape-tomania" to control them and maintain the power structure of white supremacy. She also discusses how racism influenced the diagnostic process during the Civil Rights Movement, with Black individuals being described as threatening, aggressive, and dangerous. Dr. Anglin emphasizes the importance of understanding the extended psychosis phenotype, a spectrum of experiences and symptoms that includes subclinical and clinical presentations of psychosis. She discusses the prevalence of psychotic experiences in people of color and how social factors like racial discrimination and trauma can influence the expression of these experiences. Finally, she suggests factors that can improve the clinical assessment of psychosis in racially minoritized groups, including cultural humility, awareness of biases in the therapeutic relationship, and discussing race and discrimination openly with patients.
Keywords
race
culture
psychosis
schizophrenia
black individuals
mental health clinicians
cultural mistrust
racial discrimination
psychiatric diagnoses
extended psychosis phenotype
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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