CLINICAL HANDBOOK OF SCHIZOPHRENIA

60. Schizophrenia in African Americans 617veys have tended to support this interpretation as well. The Epidemiologic CatchmentArea study, which sampled five major cities and oversampled ethnic minorities, found nodifference between African Americans and other ethnic groups when socioeconomic classwas controlled. The National Cormobidity Survey and the more recent NationalComorbidity Survey Replication found that African Americans were less likely to havenonaffective psychosis, which is primarily schizophrenia.Nevertheless, recent clinical studies continue to report an overdiagnosis of schizophreniain African Americans despite controls for a variety of settings. Table 60.1 summarizesreports comparing rates of schizophrenia by race. These findings show that theoverdiagnosis occurs in juvenile facilities, in the Veterans Administration, and in publicand private facilities. The overdiagnosis occurs despite the use of structured interview instruments.The development of DSM-III has certainly improved validity and diagnosis ofpsychiatric disorders. However, consistent use of DSM-III and now DSM-IV often doesnot prevent the misdiagnosing of African Americans. Strakowski and colleagues (2003)showed that the misdiagnosis was not the consequence of the misapplication of diagnosticcriteria (i.e., variance in criteria). Rather, information variance (failure to obtain adequateinformation) was more of a factor. In addition, African Americans with affectivedisorders are more likely to have prominent first-rank psychotic symptoms than EuropeanAmericans, which uninformed clinicians often interpret as evidence for schizophrenia,while overlooking affective symptoms. Other factors include clinician bias based onpreconceived notions about the presence of affective disorders in African Americans, lackof familiarity with culture-based idioms of distress, and social distance.Patient factors may also be involved. The increased likelihood of diagnosing psychoticsymptoms in African Americans may be a result of misinterpretation of otherintrapsychic experiences. African Americans without schizophrenia are more likely to reportdissociative symptoms. Paranoia, which is often reported, is frequently seen on olderversions of the Minnesota Multiphasic Personality Inventory (MMPI). A cultural reticenceto disclose inner feelings to strangers of a different ethnicity is often reported andhas been referred to as a “healthy paranoia.” African Americans often delay or do notseek mental health treatment until symptoms are severe, thereby making diagnosis difficult.Clearly, the diagnosis of schizophrenia in African Americans should be made onlyafter other, alternative diagnoses are considered.In summary, in diagnosing African Americans and other ethnic groups as well, allsources of information should be included. Family members, caretakers, and past medicalrecords should be consulted. Premature closure should be avoided when a patient presentswith psychotic symptoms. It is important to remember that hallucinations may occurin affective and anxiety disorders, especially when treatment has been delayed. Close adherenceto DSM-IV criteria should be encouraged, with the recognition that DSM-IVdoes not exclude mood or anxiety disorders when psychotic symptoms are present. Certainlyawareness of cultural issues, such as specific idioms of distress, should be recognized. It isdifficult to know the nuances of every culture, which is why sources other then thepatient must be consulted. Whatever the case, the diagnosis of schizophrenia should bepresumptive for African Americans only when other diagnoses are excluded.GENETIC FACTORSThroughout much of the 20th century, schizophrenia was thought to be the result of familypathology. A diathesis–stress model is now prevalent. Schizophrenia clearly has a geneticrisk, since a heavy loading of biological relatives increases the risk.