Elsevier

Schizophrenia Research

Volume 253, March 2023, Pages 5-13
Schizophrenia Research

Racial microaggressions and major discriminatory events explain ethnoracial differences in psychotic experiences

https://doi.org/10.1016/j.schres.2021.10.014Get rights and content

Abstract

Few empirical studies have examined whether exposure to major racial discrimination explains ethnoracial disparities in psychosis outcomes and none to our knowledge have done so in the U.S. or have examined the role of other forms of racism such as racial microaggressions. The present study examined ethnoracial differences in self-reported psychotic experiences (PE) among 955 college students in an urban environment in the Northeastern U.S., and the degree to which major experiences of racial discrimination and racial microaggressions explains ethnoracial differences in PE. Mean scores on self-report inventories of PE and distressing PE (i.e., Prodromal Questionnaire (PQ)), major experiences of racial discrimination (EOD), and racial and ethnic microaggressions (REMS) were compared across 4 ethnoracial groups (White, Black, Asian, and Latina/o). Results from parallel mediation linear regression models adjusted for immigrant status, age, gender, and family poverty using the Hayes PROCESS application indicated ethnoracial differences in PE were explained independently by both forms of racism. Specifically, Black young people reported higher mean levels of PE, and distressing PE than both White and Latina/o people and the difference in PE between Black and White and Black and Latino/a young people was significantly explained by both greater exposure to racial microaggressions and major racial discriminatory experiences among Black people. This study re-emphasizes the explanatory role of racism, in its multiple forms, for psychosis risk among Black young populations in the US. Anti-racism interventions at both structural and interpersonal levels are necessary components of public health efforts to improve mental health in Black populations.

Introduction

Ethnoracial differences in psychosis have been demonstrated across the psychosis continuum, from psychotic disorders (Olbert et al. (2018) to weaker expressions of positive psychotic symptoms that may not meet clinical threshold, i.e., psychotic experiences (PE) (Cohen and Marino, 2013; Olfson et al., 2002). In the U.S., studies generally find Black individuals are overrepresented among patient populations with schizophrenia in clinical settings, in part because of provider biases (Anglin and Malaspina, 2008; Schwartz and Blankenship, 2014; Strakowski et al., 1996), and that both Black and Latina/o groups are more likely than White groups to report psychotic symptoms in general population samples (Cohen and Marino, 2013; Olfson et al., 2002). Specifically, a meta-analysis showed that U.S. Latina/o (OR 1.98, 95% CI 1.43–2.73), and Black (OR 1.85, 95% CI 1.39–2.47) populations report more PE than White populations (Leaune et al., 2019). Given only 4/19 samples in this meta-analysis were U.S.-based, more replication is needed across multiple US settings, especially given the unique historical racialization of U.S. socioeconomic and sociopolitical systems and their impact on racial inequities in health (e.g., racialized capitalism) (Laster Pirtle, 2020; Robinson, 1983).

Structural racism is a socially constructed taxonomic stratification of power based on proximity to Whiteness that preferentially distributes societal resources to groups based on this stratification (Guess, 2006). Racism is perpetuated within and through institutional structures (e.g., education, policing) (Williams and Williams-Morris, 2000) and through interpersonal discriminatory experiences of unfair treatment by dominant group members (Brown et al., 2000; Feagin and Eckberg, 1980). Consequently, racial discrimination is a significant social risk factor for poor mental health outcomes (Schmitt et al., 2014; Williams et al., 2003), including for psychosis (Anglin et al., 2014; Oh et al., 2016; Oh et al., 2014; Stowkowy et al., 2016), with a recent meta-analysis (Bardol et al., 2020) demonstrating this for both psychotic symptoms (OR = 1.77, 95% CI 1.26–2.49) and psychotic experiences (OR = 1.94, 95% CI [1.42–2.67]). Another review (Pearce et al., 2019) demonstrated this relation in a dose-response fashion (e.g., Oh et al., 2016). Vulnerability-stress models propose that racial discrimination enhances psychosis risk because discrimination is perceived and experienced as stressful (Berger and Sarnyai, 2015) and even traumatic (Polanco-Roman et al., 2016) and propagated through multiple levels including neighborhood and individual-levels (Anglin et al., 2021). Yet few studies (Berg et al., 2011; Cooper et al., 2008) have directly examined whether exposure to racial discrimination explains ethnoracial differences in psychosis outcomes, and of those that have, some findings have been mixed with one study demonstrating discrimination partly explained ethnoracial differences in psychotic disorder incidence (Misra et al., 2021), and another (Jongsma et al., 2020) finding other social disadvantages explained more in ethnoracial PE differences than racial discrimination. Most importantly, no samples come from U.S. contexts and none simultaneously examine whether exposure to multiple forms of racism explain ethnoracial differences in PE.

Contemporary forms of racial discrimination tend to be subtle yet aversive (Dovidio and Gaertner, 2004; Dovidio et al., 2002). Racial microaggressions, a term first coined by Chester Pierce in the 1970's, are akin to everyday racial discrimination and represent verbal and nonverbal affronts that people of color encounter in their day-to-day interactions (Nadal, 2011; Pierce, 1970, Pierce, 1974; Sue et al., 2007) (e.g., repeatedly being called the name of the other Black student in your class). While microaggressions tend to differentially target ethnoracially minoritized groups (Lui and Anglin, 2019), White people, particularly those in diverse contexts, also report racial microaggressions despite their racial privilege in the context of racism (Meyers et al., 2020). Racial microaggressions have been associated with a host of negative mental health outcomes, including depressive symptoms (Torres et al., 2010) and suicidal ideation (O'Keefe et al., 2015), especially for Black Americans (Williams et al., 2018); but no studies to our knowledge have examined them in relation to PE.

Racial microaggressions may have particular relevance for PE due to their attributional ambiguity, i.e., uncertainty about whether to attribute negative treatment to race or some other reason (Barrett and Swim, 1998; Crocker et al., 1991). The combination of high implicit racial bias coupled with low overt racial bias creates a “mixed message” in intergroup interactions that may engender mistrust and self-doubt (Varghese et al., 2011). Because racial microaggressions require ethnoracial minoritized people to dedicate increased cognitive resources toward interpreting and navigating ambiguous behaviors, their cumulative impact may contribute to a climate of distrust and insecurity in one's perceptions and sensibilities (Anglin et al., 2014), especially if ethnoracially isolated (Anglin et al., 2020b).

The present study examined ethnoracial differences in PE in a diverse sample of emerging adults in an urban setting. This context is important given urbanicity has been identified as a risk factor for psychosis especially in high-income countries (DeVylder et al., 2018; Padhy et al., 2014). The present study examined whether two forms of racism independently explain ethnoracial differences in PE using explanatory mediation models. While both major discriminatory experiences and microaggressions could increase PE through stress, major experiences may do so because they involve structural barriers that weaken one's social position (Kessler et al., 1999; Lewis et al., 2015) and shape access to health-promoting resources and opportunities (Thomas et al., 2019); microaggressions, because of their attributional ambiguity, may do so through chronic taxing of one's cognitive and affective resources. We hypothesize Black and Latina/o people will self-report more PE than White and Asian individuals and that this will be independently explained by higher exposure to both forms of racism.

Section snippets

Sample

Participants were obtained from an urban public university system in the northeastern United States whose students reflect the diversity of the surrounding urban communities (i.e., high proportion of ethnoracial minorities and immigrants). Undergraduate students from multiple disciplines were deemed eligible if they were emerging adults and self-identified as Black/African American/African descent or as a first- or second-generation immigrant. This was meant to maximize recruitment of young

Sample characteristics

Participant demographic information and means and standard deviations for the study outcomes are presented for the entire sample and by ethnoracial group (see Table 1 for details). 71% of the sample endorsed EOD in at least one domain, and 48% in 2 or more domains. Participants who endorsed EOD tended to indicate the “on the street or in a public setting” (47%), and “at school” (39%) domains and Environmental microaggressions was the most frequently endorsed REMS subscale. The percentage of

Discussion

The present study is the first in the U.S. to demonstrate that both major experiences of racial discrimination and racial microaggressions independently explain higher self-reported PE among Black young people compared to both White and Latina/o young people. These significant direct and indirect associations were over and above ethnoracial differences in age, gender, immigrant status, and family poverty. The aforementioned findings extend to distressing psychotic experiences, which may have

Limitations and future directions

While this study adds to the literature by directly connecting higher levels of PE in Black people to higher exposure to multiple forms of racism, it is not without limitations. One limitation is the magnitude of the ethnoracial differences in PE were small, and it is possible that detecting differences in more subtle expressions of the psychosis continuum is harder in younger college populations (El Bouhaddani et al., 2019), and so microaggressions findings should be replicated in

Conclusions

Structural racism is a fundamental cause of the public health crisis that has plagued Black populations for centuries and into the present day (Cogburn, 2019). The consequential mental health burden has disproportionately taken the form of experiences and symptoms within the psychosis spectrum, which have been specifically tied to environmental risk factors (Guloksuz et al., 2015)—factors likely exacerbated by the events surrounding George Floyd's death which followed the data collection in the

Role of the funding source

The funders of this study had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

CRediT authorship contribution statement

Deidre M. Anglin, PhD, is Associate Professor of Clinical Psychology in the Department of Psychology and in the Doctoral Clinical Program at The City College of New York (CCNY) and The Graduate Center, City University of New York (CUNY). Dr. Anglin's work focuses on reducing mental health racial disparities and studying the social epidemiology of psychosis. Dr. Anglin is one of the first 100 doctoral scholars in the Leadership Alliance and a member of National Institutes of Health's National

Declaration of competing interest

The authors have no conflicts of interest to declare.

Acknowledgements

Support for this project was provided by a grant from the New York State (NYS) Center of Excellence for Cultural Competence at the NYS Psychiatric Institute, NYS Office of Mental Health (Dr. Anglin). Dr. Lui is supported by the National Cancer Institute: Institutional Training Grant, Psychosocial Palliative and Community Research in Cancer (2T32CA009461-36).

References (79)

  • S.K. Padhy et al.

    Urban living and psychosis–an overview

    Asian J. Psychiatr.

    (2014)
  • S.M. Strakowski et al.

    Racial differences in the diagnosis of psychosis

    Schizophr. Res.

    (1996)
  • C. Wilson et al.

    Context matters: the impact of neighborhood crime and paranoid symptoms on psychosis risk assessment

    Schizophr. Res.

    (2016)
  • D.M. Anglin et al.

    Ethnicity effects on clinical diagnoses compared to best-estimate research diagnoses in patients with psychosis: a retrospective medical chart review

    J. Clin. Psychiatry

    (2008)
  • D.M. Anglin et al.

    Ethnicity and psychosis: examining the nature of the relationship

  • D.M. Anglin et al.

    Racial discrimination is associated with distressing subthreshold positive psychotic symptoms among US urban ethnic minority young adults

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2014)
  • D.M. Anglin et al.

    Ethnic identity, racial discrimination and attenuated psychotic symptoms in an urban population of emerging adults

    (2018)
  • D.M. Anglin et al.

    Going upstream to advance psychosis prevention and improve public health

    JAMA Psychiatry

    (2020)
  • D.M. Anglin et al.

    From womb to neighborhood: a racial analysis of social determinants of psychosis in the United States

    Am. J. Psychiatry

    (2021)
  • S. Baker et al.

    A comprehensive systematic review and multilevel meta-analysis of the ethnic density effect in psychosis

    (2020)
  • O. Bardol et al.

    Perceived ethnic discrimination as a risk factor for psychotic symptoms: a systematic review and meta-analysis

    Psychol. Med.

    (2020)
  • A.O. Berg et al.

    Perceived discrimination is associated with severity of positive and depression/anxiety symptoms in immigrants with psychosis: a cross-sectional study

    (2011)
  • M. Berger et al.

    "More than skin deep": stress neurobiology and mental health consequences of racial discrimination

    Stress

    (2015)
  • A.S. Brittian

    Understanding African American adolescents' identity development: a relational developmental systems perspective

    J. Black Psychol.

    (2012)
  • M. Carlson et al.

    Addressing the impact of racism on veterans of color: a race-based stress and trauma intervention

    Psychol. Violence

    (2018)
  • D.C. Cicero et al.

    Measurement invariance of the Prodromal Questionnaire-Brief among White, Asian, Hispanic, and multiracial populations

    Assessment

    (2019)
  • C.D. Cogburn

    Culture, race, and health: implications for racial inequities and population health

    (2019)
  • C.I. Cohen et al.

    Racial and ethnic differences in the prevalence of psychotic symptoms in the general population

    Psychiatr. Serv.

    (2013)
  • C. Cooper et al.

    Perceptions of disadvantage, ethnicity and psychosis

    Br. J. Psychiatry

    (2008)
  • J. Crocker et al.

    Social stigma: the affective consequences of attributional ambiguity

    J. Pers. Soc. Psychol.

    (1991)
  • J.E. DeVylder et al.

    Social and psychological contributions to the co-occurrence of sub-threshold psychotic experiences and suicidal behavior

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2015)
  • J.E. DeVylder et al.

    Association of urbanicity with psychosis in low-and middle-income countries

    (2018)
  • J.F. Dovidio et al.

    Aversive racism

    (2004)
  • J.F. Dovidio et al.

    Implicit and explicit prejudice and interracial interaction

    J. Pers. Soc. Psychol.

    (2002)
  • S. El Bouhaddani et al.

    Psychotic experiences among ethnic majority and minority adolescents and the role of discrimination and ethnic identity

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2019)
  • J.R. Feagin et al.

    Discrimination: motivation, action, effects, and context

    Annu. Rev. Sociol.

    (1980)
  • T.J. Guess

    The social construction of whiteness: racism by intent, racism by consequence

    Crit. Sociol.

    (2006)
  • S. Guloksuz et al.

    Evidence that the presence of psychosis in nonpsychotic disorder is environment-dependent and mediated by severity of non-psychotic psychopathology

    (2015)
  • A.F. Hayes

    PROCESS: a versatile computational tool for observed variable mediation, moderation, and conditional process modeling

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