Ethnicity and variability of psychotic symptoms

  • William A. Vega
  • Roberto Lewis-Fernández


This review addresses the influence of ethnicity on the expression of psychotic symptoms and the implications for evaluating and treating patients of diverse backgrounds. Growing clinical and population research from Europe and the United States supports a dimensional interpretation of psychosis, yet the evidence suggests that psychotic symptoms place individuals at higher risk for a range of severe psychiatric conditions and adverse outcomes, such as suicidality. Ethnocultural diversity challenges clinicians to accurately interpret the clinical significance of patients’ symptom presentations. Disproportionate psychotic symptoms and higher rates of psychotic disorders have been found in some ethnic groups, particularly among immigrants and their offspring, but profound inconsistencies in these patterns remain. More cultural research on the clinical implications of ethnic variation in psychosis is needed. Developing awareness and requisite skills is a priority for clinicians who evaluate and recommend treatments to ethnically diverse patients.


Schizophrenia Psychotic Symptom Psychotic Disorder Traumatic Exposure Persecutive Delusion 
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References and Recommended Reading

  1. 1.
    Allardyce J, Gaebel W, Zielasek J, et al.: Deconstructing Psychosis conference February 2006: the validity of schizophrenia and alternative approaches to the classification of psychosis. Schizophr Bull 2007, 33:863–867.PubMedCrossRefGoogle Scholar
  2. 2.
    Dutta R, Greene T, Addington J, et al.: Biological, life course, and cross-cultural studies all point toward the value of dimensional and developmental ratings in the classification of psychosis. Schizophr Bull 2007, 33:868–876.PubMedCrossRefGoogle Scholar
  3. 3.
    van Os J, Hanssen M, Bijl RV, et al.: Strauss (1969) revisited: a psychosis continuum in the general population? Schizophr Res 2000, 45:11–20.PubMedCrossRefGoogle Scholar
  4. 4.
    Johns LC, van Os J: The continuity of psychotic experiences in the general population. Clin Psychol Rev 2001, 21:1125–1141.PubMedCrossRefGoogle Scholar
  5. 5.
    Allardyce J, Boydell J: Review: the wider social environment and schizophrenia. Schizophr Bull 2006, 32:592–598.PubMedCrossRefGoogle Scholar
  6. 6.
    Morgan C, Kirkbride J, Leff J, et al.: Parental separation, loss and psychosis in different ethnic groups: a case-control study. Psychol Med 2007, 37:495–503.PubMedCrossRefGoogle Scholar
  7. 7.
    Mojtabai R: Psychotic-like experiences and interpersonal violence in the general population. Soc Psychiatry Psychiatr Epidemiol 2006, 41:183–190.PubMedCrossRefGoogle Scholar
  8. 8.
    van Os J, Tamminga C: Deconstructing psychosis. Schizophr Bull 2007, 33:861–862.PubMedCrossRefGoogle Scholar
  9. 9.
    Fearon P, Kirkbride JB, Morgan C, et al.: Incidence of schizophrenia and other psychoses in ethnic minority groups: results from the MRC AESOP Study. Psychol Med 2006, 36:1541–1550.PubMedCrossRefGoogle Scholar
  10. 10.
    Cantor-Graae E, Selten JP: Schizophrenia and migration: a meta-analysis and review. Am J Psychiatry 2005, 162:12–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Lewis-Fernandez R, Horvitz-Lennon M, Blanco C, et al.: Significance of endorsement of psychotic symptoms by US Latinos. J Nerv Ment Dis 2008 (in press).Google Scholar
  12. 12.
    Vega W, Sribney W, Miskimen T, et al.: Putative psychotic symptoms in the Mexican American population: prevalence and co-occurrence with psychiatric disorders. J Nerv Ment Dis 2006, 194:471–477.PubMedCrossRefGoogle Scholar
  13. 13.
    Chen YR, Swann AC, Burt DB: Stability of diagnosis in schizophrenia. Am J Psychiatry 1996, 153:682–686.PubMedGoogle Scholar
  14. 14.
    Mukherjee S, Shukla S, Woodle J, et al.: Misdiagnosis of schizophrenia in bipolar patients: a multiethnic comparison. Am J Psychiatry 1983, 140:1571–1574.PubMedGoogle Scholar
  15. 15.
    Trierweiler SJ, Neighbors HW, Munday C, et al.: Differences in patterns of symptom attribution in diagnosing schizophrenia between African American and non-African American clinicians. Am J Orthopsychiatry 2006, 76:154–160.PubMedCrossRefGoogle Scholar
  16. 16.
    Vega WA, Karno M, Alegria M, et al.: Research issues for improving treatment of U.S. Hispanics with persistent mental disorders. Psychiatr Serv 2007, 58:385–394.PubMedCrossRefGoogle Scholar
  17. 17.
    Lawson WB: Schizophrenia in African Americans. In Clinical Handbook of Schizophrenia. Edited by Mueser KT, Jeste DV. New York: Guilford Press; 2008 (in press).Google Scholar
  18. 18.
    Strakowski SM, Hawkins JM, Keck PE, et al.: The effects of race and information variance on disagreement between psychiatric emergency service and research diagnoses in first-episode psychosis. J Clin Psychiatry 1997, 58:457–463.PubMedGoogle Scholar
  19. 19.
    Bresnahan M, Begg MD, Brown A, et al.: Race and risk of schizophrenia in a US birth cohort: another example of health disparity? Int J Epidemiol 2007, 36:751–758.PubMedCrossRefGoogle Scholar
  20. 20.
    Williams DR, Earl TR: Commentary: Race and mental health: more questions than answers. Int J Epidemiol 2007, 36:758–760.PubMedCrossRefGoogle Scholar
  21. 21.
    Strakowski SM, Flaum M, Amador X, et al.: Racial differences in the diagnosis of psychosis. Schizophr Res 1996, 21:117–124.PubMedCrossRefGoogle Scholar
  22. 22.
    Yamada AM, Barrio C, Morrison SW, et al.: Cross-ethnic evaluation of psychotic symptom content in hospitalized middle-aged and older adults. Gen Hosp Psychiatry 2006, 28:161–168.PubMedCrossRefGoogle Scholar
  23. 23.
    Barrio C, Yamada AM, Atuel H, et al.: A tri-ethnic examination of symptom expression on the positive and negative syndrome scale in schizophrenia spectrum disorders. Schizophr Res 2003, 60:259–269.PubMedCrossRefGoogle Scholar
  24. 24.
    Minsky S, Vega W, Miskimen T, et al.: Diagnostic patterns in Latino, African American, and European American psychiatric patients. Arch Gen Psychiatry 2003, 60:637–644.PubMedCrossRefGoogle Scholar
  25. 25.
    Olfson M, Lewis-Fernández R, Weissman MM, et al.: Psychotic symptoms in an urban general medicine practice. Am J Psychiatry 2002, 159:1412–1419.PubMedCrossRefGoogle Scholar
  26. 26.
    Escobar JI, Vega WA: Mental health and immigration’s AAAs: where are we and where do we go from here? J Nerv Ment Dis 2000, 188:736–740.PubMedCrossRefGoogle Scholar
  27. 27.
    Scott J, Chant D, Andrews G, et al.: Association between trauma exposure and delusional experiences in a large community-based sample. Br J Psychiatry 2007, 190:339–343.PubMedCrossRefGoogle Scholar
  28. 28.
    Spauwen J, Krabbendam L, Lieb R, et al.: Impact of psychological trauma on the development of psychotic symptoms: relationship with psychosis proneness. Br J Psychiatry 2006, 188:527–533.PubMedCrossRefGoogle Scholar
  29. 29.
    Cougnard A, Marcelis M, Myin-Germeys I, et al.: Does normal developmental expression of psychosis combine with environmental risk to cause persistence of psychosis? A psychosis proneness-persistence model. Psychol Med 2007, 374:513–527.CrossRefGoogle Scholar
  30. 30.
    Lewis-Fernandez R, Martinez-Taboas A, Sar V, et al.: The cross-cultural assessment of dissociation. In The Cross-Cultural Assessment of Psychological Trauma and PTSD. Edited by Wilson JP, Tang C. New York: Springer; 2007:279–317.CrossRefGoogle Scholar
  31. 31.
    van Ijzendoorn MH, Schuengel C: The measurement of dissociation in normal and clinical populations: meta-analytic validation of the Dissociative Experiences Scale (DES). Clin Psychol Rev 1996, 16:365–382.CrossRefGoogle Scholar
  32. 32.
    Martinez-Taboas A, Canino G, Wang MQ, et al.: Prevalence and victimization correlates of pathological dissociation in a community sample of youths. J Trauma Stress 2006, 19:439–448.PubMedCrossRefGoogle Scholar
  33. 33.
    Moskowitz AK, Barker-Collo S, Ellson L: Replication of dissociation-psychosis link in New Zealand students and inmates. J Nerv Ment Dis 2005, 193:722–727.PubMedCrossRefGoogle Scholar
  34. 34.
    Allen JG, Coyne L, Console DA: Dissociative detachment relates to psychotic symptoms and personality decompensation. Compr Psychiatry 1997, 38:327–334.PubMedCrossRefGoogle Scholar
  35. 35.
    Sar V, Ozturk E: Psychotic presentations of dissociative identity disorder. In Dissociation and Dissociative Disorders: DSM-V and Beyond. Edited by Dell P, O’Neil J. New York: Routledge; 2008 (in press).Google Scholar
  36. 36.
    Tutkun H, Yargic LI, Sar V: Dissociative identity disorder presenting as hysterical psychosis. Dissociation 1996, 9:244–252.Google Scholar
  37. 37.
    David D, Kutcher GS, Jackson EI, et al.: Psychotic symptoms in combat-related posttraumatic stress disorder. J Clin Psychiatry 1999, 60:29–32.PubMedGoogle Scholar
  38. 38.
    Mueser KT, Butler RW: Auditory hallucinations in combat-related chronic posttraumatic stress disorder. J Nerv Ment Dis 1987, 144:299–302.Google Scholar
  39. 39.
    Susser E, Varma VK, Malhotra S, et al.: Delineation of acute and transient psychotic disorders in a developing country setting. Br J Psychiatry 1995, 167:216–219.PubMedCrossRefGoogle Scholar
  40. 40.
    Corin E: The “other” of culture and psychosis: the ex-centricity of the subject. In Subjectivity: Ethnographic Investigations. Edited by Biehl J, Good B, Kleinman A. Berkeley, CA: University of California Press; 2007:273–314.Google Scholar
  41. 41.
    Lewis-Fernández R, Díaz N: The cultural formulation: a method for assessing cultural factors affecting the clinical encounter. Psychiatr Q 2002, 73:271–295.PubMedCrossRefGoogle Scholar
  42. 42.
    Morgan C, Mallett R, Hutchinson G, et al.: Pathways to care and ethnicity. 2: Source of referral and help-seeking. Report from the AESOP study. Br J Psychiatry 2005, 186:290–296.PubMedCrossRefGoogle Scholar
  43. 43.
    Rogler LH, Cortés DE: Help-seeking pathways: a unifying concept in mental health care. Am J Psychiatry 1993, 150:554–561.PubMedGoogle Scholar
  44. 44.
    Jenkins JH, Karno M: The meaning of expressed emotion: theoretical issues raised by cross-cultural research. Am J Psychiatry 1992, 149:9–21.PubMedGoogle Scholar
  45. 45.
    Guarnaccia PJ, Parra P, Deschamps A, et al.: Si dios quiere: Hispanic families’ experiences of caring for a seriously mentally ill family member. Cult Med Psychiatry 1992, 16:187–215.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group LLC 2008

Authors and Affiliations

  1. 1.Department of Family Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesUSA

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