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Discrimination Race Gender amp APPS 1
Discrimination may contribute to a higher endorsement of Attenuated Positive Psychotic Symptoms (APPS) in black compared to white college students irrespective of gender
Angelo Laine
Mentor Deidre Anglin PhD
Department of Psychology
City College of New York
May 25th 2015
Discrimination Race Gender amp APPS 2
Abstract
Background Studies have shown that psychotic disorders are part of a spectrum
meaning that their symptoms extend to the general population in attenuated forms Both
clinically psychotic individuals and attenuated forms of the disorders are subject to the same risk
factors
Currently we know that the incidence of schizophrenia is gendered and that ethnic
minorities are at increased risk for psychosis Ochoa et al (2008) found a 14 rate ratio male to
female in the incidence of schizophrenia but studies are inconclusive at finding similar results in
the prodromal phase of psychosis Ethnic minorities have been found to be at a higher risk for
psychosis and a higher endorsement of attenuated positive psychotic symptoms in the presence
of discrimination
Objective The study had two main aims first a women to men difference in APPS
should be present in blacks as long as it is sufficiently mediated by discrimination since
discrimination is a gendered experience secondly due to discrimination such gender difference
in APPS in the black group should be significantly higher than the ones that may be found in
white individuals
Methods amp Results A sample of 1633 young adults who self-identified as black or
whites were recruited from two US Northeast colleges They completed self-report
questionnaires of APPS experiences of discrimination Our results showed that black individuals
irrespective of gender reported more discrimination endorsed more APPS and distressing APPS
than white individuals We also found a gender difference among black individuals in term of
APPS categories and discrimination However discrimination may only partially mediate the
relation between race and gender in regard to APPS in the black sub-sample
Discrimination Race Gender amp APPS 3
Psychosis characteristics
Psychotic disorders including schizophrenia are disorders exhibiting symptoms in at
least one or more of the following domains ldquodelusions hallucinations disorganized thinking
(speech) grossly disorganized or abnormal motor behavior (including catatonia) and negative
symptomsrdquo (American Psychiatric Association [APA] 2013 p 87) Delusions and hallucinations
are also known as positive symptoms which are considered to be excess in onersquos normal
behavior (Sims 2002) The definition of delusion is to firmly hold onto beliefs that are
contradictory to reality and to counterevidence (APA 2013) Such beliefs may appear in
different forms Persecutory delusions are the beliefs that one is under the constant threat of
harm harassment and so on from individuals organizations or other groups (APA 2013)
Grandiose delusions are an exaggerated sense of self in regard to onersquos abilities wealth or fame
(APA 2013) Somatic delusions are excessive preoccupations in regards to onersquos health (APA
2013) Referential delusions refer to the beliefs that gestures comments made by people objects
or even environmental cues are actually directed to oneself (APA 2013) Hallucinations refer to
auditory or visuals experiences reported by psychotic individuals that happen in the absence of
stimulus from the environment
Negatives symptoms which are comprised of avolition asociability anhedonia blunted
effect and alogia refer to deficit in normal behavior (Sims 2002) Such symptoms are more
common in schizophrenia than other psychotic disorders (APA 2013) Psychotic individuals
may for example regress from their daily hygiene routine from work or school work also
known as avolition They may speak very little or not speak at all for an extended amount of
time a symptom known alogia They may lose their interests in social activities and interactions
Discrimination Race Gender amp APPS 4
such as losing contact with friends which results in their own isolation also known as
asociability They experience less pleasure and express less expression emotion known as
blunted effect and anhedonia
Disorganized thinking refers to onersquos incoherent and incomprehensible speech pattern
Grossly disorganized or abnormal motor behavior refers to onersquos inability to conform to
community standards Those behaviors are varied One group of such behaviors catatonia for
example is defined by a ldquomarked decrease in reactivity to the environmentrdquo (APA 2013 p 88)
Catatonic behaviors can be a ldquoresistance to instructions or negativismrdquo the ldquomaintenance of a
rigid or inappropriate posturerdquo known as mutism the ldquocomplete lack of verbal and motor
responsesrdquo known as stupor finally ldquopurposeless and excessive motor activity without obvious
causesrdquo also known as catatonic excitement (APA 2013 p 88) But abnormal motor behaviors
can also be very ldquochildlike to unpredictable agitationrdquo that may interfere with their daily
activities (APA 2013 p 88)
Schizophrenia and the psychotic spectrum
Schizophrenia is a brain disorder that ldquoinvolves a range of emotional cognitive and
behavioral dysfunctionsrdquo (APA 2013 p 99) According to the 5th and latest edition of the
diagnostic statistical manual for mental disorders (APA 2013) the diagnostic criteria belonging
to schizophrenia are as follow the patient should exhibit symptoms belonging to two or more of
the psychotic domains for a significant amount of time during a 1 month period At least 6
months of marked decrease in level of functioning in one or more major areas like work or
interpersonal relationships should be present Finally none of the symptoms can be explained by
any other disorders Persecutory delusions and auditory hallucinations are the two most
Discrimination Race Gender amp APPS 5
commons schizophrenic symptoms (Sartorius Shapiro Jablonksy 1974) Currently in the
United States about 03 to 07 of the population suffers from schizophrenia (APA 2013)
Schizophrenia is surprisingly a very costly disease In the year 2002 in the United States
Wu et al (2005) estimated that schizophreniarsquos financial impact to be at 627 billion US dollars
(USD) from data collected from privately and publicly insured patients Similar results were
found in other countries Phanthunane Whiteford Vos Bertram (2012) estimated from data
collected in 2008 that schizophreniarsquos financial impact in Thailand was 925 million USD
Magalore amp Knapp (2007) estimated schizophreniarsquos cost to be 67 billion pounds in England for
the 20042005 year It should be noted that in all three studies indirect costs consisted the
majority of the financial impact Wu et al (2005) only attributed 225 billon USD of direct costs
associated to the disease in term of medications treatments and else while Magalore amp Knapp
(2007) attributed 2 billion of the financial costs of the disease to direct cost Phanthumane et al
(2012) said that unemployment was the biggest culprit in the total financial costs in Thailand
It is possible to predict someonersquos risk The most well-known way to predict the risk of
schizophrenia in individuals is through their family history Indeed it has been shown that
schizophrenia has a strong genetic component While the general population lifetime risk to
develop schizophrenia is less than 1 children whose at least one of their parents has
schizophrenia have a 13 chance to develop it too (McGuffin Gottesman Farmer 1987) The
risk is higher in fraternal and identical twins with a 17 and 48 risk respectively (Mc
Gruffin et al 1987)
Furthermore schizophrenia and other psychotic disorders are part of the psychotic
spectrum The psychotic spectrum refers to the continuum of distressing or non-distressing
Discrimination Race Gender amp APPS 6
subclinical psychotic symptoms experienced by the general population that may in turn progress
to the full blown clinical symptoms diagnosed in psychotic disorders ((Dhossche et al 2002
Hanssen et al 2005 Wiles et al 2006 Dominguez et al 2011) In other words the diagnosis of
prodromal symptoms in an individual does not mean he will be psychotic in the future As a
matter of fact subclinical psychotic symptoms are actually common in the general population A
recent systematic meta-analysis found a median prevalence of 5 and a median incidence rate of
3 for prodromal psychotic symptoms and 75-90 of those symptoms disappeared over time
(van Os Linscott Myin-Germeys Delespaul and Krabbendam 2009) To reflect the uncertain
transient nature of subclinical psychotic symptoms a group of researchers proposed the term at
ldquorisk for mental staterdquo to imply that the individuals in the early phase of the disorder may never
fully develop the disorder They preferred their term to the word ldquoprodromerdquo which they stated
was a medical term that refers to the early signs of a disease and therefore alluded that the
disease will soon follow up (Yung et al p286) Indeed ldquofalse false positiverdquo individuals are
people who ldquowould have the same vulnerability markers as the true positives who do progress
from an at-risk mental state to psychosis but because of resilience or protective factors do not
make the transitionrdquo ( Yung et al 1996 p 288) Only a small amount of people with prodromal
symptoms makes the conversion to psychosis Yung et al (1996) found that only 212 of their
small sample (N=33) of at-risk for psychosis patients transitioned within 12 months In another
study about 40 of the high risk patients transitioned to clinical psychotic disorders within 12
months (Yung et al 1998)
The development of subclinical psychosis and its transition to clinical psychosis is
dependent on many factors After determining the amount of patients who transitioned to
psychosis Yung et al (2003) determined what were the highly predictors of psychosis of their
Discrimination Race Gender amp APPS 7
sample (N=49) They have found that individuals who have been experiencing the prodromal
symptoms for a long amount of time before diagnosis who were functioning poorly at intake and
expressed severe psychotic symptoms were at a significant risk to transition to psychosis
Subsequently the risk factors associated with the developing schizophrenia are the same as for
developing its milder symptoms Van Os et al (2009) did a systematic review of 1558 papers
published in the past 5 years at the time of the publication of their article They reported the same
risk of developing schizophrenia were also in its prodromal symptoms We can infer from those
information that the development of subclinical psychosis is heavily dependent onersquos level of
exposure to psychotic risk factors (van Os et al 2009) which in turn may transition to clinical
psychosis due to the length and severity of the symptoms experienced causing a decrease in the
level of functioning in the individual (Yung et al 1998)
Diagnosis of Subclinical Psychotic Symptoms
There are many instruments that can be used to diagnose prodromal symptoms in
individuals and the Structured Interview for Prodromal Syndromes (SIPS) is one of those
instruments (McGlasan et al 2001 Miller et al 2003 Rosen et al 2002 Miller et al 1999) A
trained professional expecting to use the SIPS will find the following measures the scale of
prodromal symptoms (SOPS) the schizotypal Personality Disorder Checklist based on the DSM
IV the family history questionnaire and the global assessment of functioning scale (Miller et al
2003) The family history section assesses the patientrsquos socio-demographic background
Information regarding a personal or family history of psychosis trauma and substance use is also
gathered there The Schizotypal personality disorder assesses the presence of the disorder in the
patient Five or more of the symptoms as listed in the DSM IV must be met for a full diagnosis
The SOPS is a 19 item questionnaire used to assess the severity onset and frequency of
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 2
Abstract
Background Studies have shown that psychotic disorders are part of a spectrum
meaning that their symptoms extend to the general population in attenuated forms Both
clinically psychotic individuals and attenuated forms of the disorders are subject to the same risk
factors
Currently we know that the incidence of schizophrenia is gendered and that ethnic
minorities are at increased risk for psychosis Ochoa et al (2008) found a 14 rate ratio male to
female in the incidence of schizophrenia but studies are inconclusive at finding similar results in
the prodromal phase of psychosis Ethnic minorities have been found to be at a higher risk for
psychosis and a higher endorsement of attenuated positive psychotic symptoms in the presence
of discrimination
Objective The study had two main aims first a women to men difference in APPS
should be present in blacks as long as it is sufficiently mediated by discrimination since
discrimination is a gendered experience secondly due to discrimination such gender difference
in APPS in the black group should be significantly higher than the ones that may be found in
white individuals
Methods amp Results A sample of 1633 young adults who self-identified as black or
whites were recruited from two US Northeast colleges They completed self-report
questionnaires of APPS experiences of discrimination Our results showed that black individuals
irrespective of gender reported more discrimination endorsed more APPS and distressing APPS
than white individuals We also found a gender difference among black individuals in term of
APPS categories and discrimination However discrimination may only partially mediate the
relation between race and gender in regard to APPS in the black sub-sample
Discrimination Race Gender amp APPS 3
Psychosis characteristics
Psychotic disorders including schizophrenia are disorders exhibiting symptoms in at
least one or more of the following domains ldquodelusions hallucinations disorganized thinking
(speech) grossly disorganized or abnormal motor behavior (including catatonia) and negative
symptomsrdquo (American Psychiatric Association [APA] 2013 p 87) Delusions and hallucinations
are also known as positive symptoms which are considered to be excess in onersquos normal
behavior (Sims 2002) The definition of delusion is to firmly hold onto beliefs that are
contradictory to reality and to counterevidence (APA 2013) Such beliefs may appear in
different forms Persecutory delusions are the beliefs that one is under the constant threat of
harm harassment and so on from individuals organizations or other groups (APA 2013)
Grandiose delusions are an exaggerated sense of self in regard to onersquos abilities wealth or fame
(APA 2013) Somatic delusions are excessive preoccupations in regards to onersquos health (APA
2013) Referential delusions refer to the beliefs that gestures comments made by people objects
or even environmental cues are actually directed to oneself (APA 2013) Hallucinations refer to
auditory or visuals experiences reported by psychotic individuals that happen in the absence of
stimulus from the environment
Negatives symptoms which are comprised of avolition asociability anhedonia blunted
effect and alogia refer to deficit in normal behavior (Sims 2002) Such symptoms are more
common in schizophrenia than other psychotic disorders (APA 2013) Psychotic individuals
may for example regress from their daily hygiene routine from work or school work also
known as avolition They may speak very little or not speak at all for an extended amount of
time a symptom known alogia They may lose their interests in social activities and interactions
Discrimination Race Gender amp APPS 4
such as losing contact with friends which results in their own isolation also known as
asociability They experience less pleasure and express less expression emotion known as
blunted effect and anhedonia
Disorganized thinking refers to onersquos incoherent and incomprehensible speech pattern
Grossly disorganized or abnormal motor behavior refers to onersquos inability to conform to
community standards Those behaviors are varied One group of such behaviors catatonia for
example is defined by a ldquomarked decrease in reactivity to the environmentrdquo (APA 2013 p 88)
Catatonic behaviors can be a ldquoresistance to instructions or negativismrdquo the ldquomaintenance of a
rigid or inappropriate posturerdquo known as mutism the ldquocomplete lack of verbal and motor
responsesrdquo known as stupor finally ldquopurposeless and excessive motor activity without obvious
causesrdquo also known as catatonic excitement (APA 2013 p 88) But abnormal motor behaviors
can also be very ldquochildlike to unpredictable agitationrdquo that may interfere with their daily
activities (APA 2013 p 88)
Schizophrenia and the psychotic spectrum
Schizophrenia is a brain disorder that ldquoinvolves a range of emotional cognitive and
behavioral dysfunctionsrdquo (APA 2013 p 99) According to the 5th and latest edition of the
diagnostic statistical manual for mental disorders (APA 2013) the diagnostic criteria belonging
to schizophrenia are as follow the patient should exhibit symptoms belonging to two or more of
the psychotic domains for a significant amount of time during a 1 month period At least 6
months of marked decrease in level of functioning in one or more major areas like work or
interpersonal relationships should be present Finally none of the symptoms can be explained by
any other disorders Persecutory delusions and auditory hallucinations are the two most
Discrimination Race Gender amp APPS 5
commons schizophrenic symptoms (Sartorius Shapiro Jablonksy 1974) Currently in the
United States about 03 to 07 of the population suffers from schizophrenia (APA 2013)
Schizophrenia is surprisingly a very costly disease In the year 2002 in the United States
Wu et al (2005) estimated that schizophreniarsquos financial impact to be at 627 billion US dollars
(USD) from data collected from privately and publicly insured patients Similar results were
found in other countries Phanthunane Whiteford Vos Bertram (2012) estimated from data
collected in 2008 that schizophreniarsquos financial impact in Thailand was 925 million USD
Magalore amp Knapp (2007) estimated schizophreniarsquos cost to be 67 billion pounds in England for
the 20042005 year It should be noted that in all three studies indirect costs consisted the
majority of the financial impact Wu et al (2005) only attributed 225 billon USD of direct costs
associated to the disease in term of medications treatments and else while Magalore amp Knapp
(2007) attributed 2 billion of the financial costs of the disease to direct cost Phanthumane et al
(2012) said that unemployment was the biggest culprit in the total financial costs in Thailand
It is possible to predict someonersquos risk The most well-known way to predict the risk of
schizophrenia in individuals is through their family history Indeed it has been shown that
schizophrenia has a strong genetic component While the general population lifetime risk to
develop schizophrenia is less than 1 children whose at least one of their parents has
schizophrenia have a 13 chance to develop it too (McGuffin Gottesman Farmer 1987) The
risk is higher in fraternal and identical twins with a 17 and 48 risk respectively (Mc
Gruffin et al 1987)
Furthermore schizophrenia and other psychotic disorders are part of the psychotic
spectrum The psychotic spectrum refers to the continuum of distressing or non-distressing
Discrimination Race Gender amp APPS 6
subclinical psychotic symptoms experienced by the general population that may in turn progress
to the full blown clinical symptoms diagnosed in psychotic disorders ((Dhossche et al 2002
Hanssen et al 2005 Wiles et al 2006 Dominguez et al 2011) In other words the diagnosis of
prodromal symptoms in an individual does not mean he will be psychotic in the future As a
matter of fact subclinical psychotic symptoms are actually common in the general population A
recent systematic meta-analysis found a median prevalence of 5 and a median incidence rate of
3 for prodromal psychotic symptoms and 75-90 of those symptoms disappeared over time
(van Os Linscott Myin-Germeys Delespaul and Krabbendam 2009) To reflect the uncertain
transient nature of subclinical psychotic symptoms a group of researchers proposed the term at
ldquorisk for mental staterdquo to imply that the individuals in the early phase of the disorder may never
fully develop the disorder They preferred their term to the word ldquoprodromerdquo which they stated
was a medical term that refers to the early signs of a disease and therefore alluded that the
disease will soon follow up (Yung et al p286) Indeed ldquofalse false positiverdquo individuals are
people who ldquowould have the same vulnerability markers as the true positives who do progress
from an at-risk mental state to psychosis but because of resilience or protective factors do not
make the transitionrdquo ( Yung et al 1996 p 288) Only a small amount of people with prodromal
symptoms makes the conversion to psychosis Yung et al (1996) found that only 212 of their
small sample (N=33) of at-risk for psychosis patients transitioned within 12 months In another
study about 40 of the high risk patients transitioned to clinical psychotic disorders within 12
months (Yung et al 1998)
The development of subclinical psychosis and its transition to clinical psychosis is
dependent on many factors After determining the amount of patients who transitioned to
psychosis Yung et al (2003) determined what were the highly predictors of psychosis of their
Discrimination Race Gender amp APPS 7
sample (N=49) They have found that individuals who have been experiencing the prodromal
symptoms for a long amount of time before diagnosis who were functioning poorly at intake and
expressed severe psychotic symptoms were at a significant risk to transition to psychosis
Subsequently the risk factors associated with the developing schizophrenia are the same as for
developing its milder symptoms Van Os et al (2009) did a systematic review of 1558 papers
published in the past 5 years at the time of the publication of their article They reported the same
risk of developing schizophrenia were also in its prodromal symptoms We can infer from those
information that the development of subclinical psychosis is heavily dependent onersquos level of
exposure to psychotic risk factors (van Os et al 2009) which in turn may transition to clinical
psychosis due to the length and severity of the symptoms experienced causing a decrease in the
level of functioning in the individual (Yung et al 1998)
Diagnosis of Subclinical Psychotic Symptoms
There are many instruments that can be used to diagnose prodromal symptoms in
individuals and the Structured Interview for Prodromal Syndromes (SIPS) is one of those
instruments (McGlasan et al 2001 Miller et al 2003 Rosen et al 2002 Miller et al 1999) A
trained professional expecting to use the SIPS will find the following measures the scale of
prodromal symptoms (SOPS) the schizotypal Personality Disorder Checklist based on the DSM
IV the family history questionnaire and the global assessment of functioning scale (Miller et al
2003) The family history section assesses the patientrsquos socio-demographic background
Information regarding a personal or family history of psychosis trauma and substance use is also
gathered there The Schizotypal personality disorder assesses the presence of the disorder in the
patient Five or more of the symptoms as listed in the DSM IV must be met for a full diagnosis
The SOPS is a 19 item questionnaire used to assess the severity onset and frequency of
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 3
Psychosis characteristics
Psychotic disorders including schizophrenia are disorders exhibiting symptoms in at
least one or more of the following domains ldquodelusions hallucinations disorganized thinking
(speech) grossly disorganized or abnormal motor behavior (including catatonia) and negative
symptomsrdquo (American Psychiatric Association [APA] 2013 p 87) Delusions and hallucinations
are also known as positive symptoms which are considered to be excess in onersquos normal
behavior (Sims 2002) The definition of delusion is to firmly hold onto beliefs that are
contradictory to reality and to counterevidence (APA 2013) Such beliefs may appear in
different forms Persecutory delusions are the beliefs that one is under the constant threat of
harm harassment and so on from individuals organizations or other groups (APA 2013)
Grandiose delusions are an exaggerated sense of self in regard to onersquos abilities wealth or fame
(APA 2013) Somatic delusions are excessive preoccupations in regards to onersquos health (APA
2013) Referential delusions refer to the beliefs that gestures comments made by people objects
or even environmental cues are actually directed to oneself (APA 2013) Hallucinations refer to
auditory or visuals experiences reported by psychotic individuals that happen in the absence of
stimulus from the environment
Negatives symptoms which are comprised of avolition asociability anhedonia blunted
effect and alogia refer to deficit in normal behavior (Sims 2002) Such symptoms are more
common in schizophrenia than other psychotic disorders (APA 2013) Psychotic individuals
may for example regress from their daily hygiene routine from work or school work also
known as avolition They may speak very little or not speak at all for an extended amount of
time a symptom known alogia They may lose their interests in social activities and interactions
Discrimination Race Gender amp APPS 4
such as losing contact with friends which results in their own isolation also known as
asociability They experience less pleasure and express less expression emotion known as
blunted effect and anhedonia
Disorganized thinking refers to onersquos incoherent and incomprehensible speech pattern
Grossly disorganized or abnormal motor behavior refers to onersquos inability to conform to
community standards Those behaviors are varied One group of such behaviors catatonia for
example is defined by a ldquomarked decrease in reactivity to the environmentrdquo (APA 2013 p 88)
Catatonic behaviors can be a ldquoresistance to instructions or negativismrdquo the ldquomaintenance of a
rigid or inappropriate posturerdquo known as mutism the ldquocomplete lack of verbal and motor
responsesrdquo known as stupor finally ldquopurposeless and excessive motor activity without obvious
causesrdquo also known as catatonic excitement (APA 2013 p 88) But abnormal motor behaviors
can also be very ldquochildlike to unpredictable agitationrdquo that may interfere with their daily
activities (APA 2013 p 88)
Schizophrenia and the psychotic spectrum
Schizophrenia is a brain disorder that ldquoinvolves a range of emotional cognitive and
behavioral dysfunctionsrdquo (APA 2013 p 99) According to the 5th and latest edition of the
diagnostic statistical manual for mental disorders (APA 2013) the diagnostic criteria belonging
to schizophrenia are as follow the patient should exhibit symptoms belonging to two or more of
the psychotic domains for a significant amount of time during a 1 month period At least 6
months of marked decrease in level of functioning in one or more major areas like work or
interpersonal relationships should be present Finally none of the symptoms can be explained by
any other disorders Persecutory delusions and auditory hallucinations are the two most
Discrimination Race Gender amp APPS 5
commons schizophrenic symptoms (Sartorius Shapiro Jablonksy 1974) Currently in the
United States about 03 to 07 of the population suffers from schizophrenia (APA 2013)
Schizophrenia is surprisingly a very costly disease In the year 2002 in the United States
Wu et al (2005) estimated that schizophreniarsquos financial impact to be at 627 billion US dollars
(USD) from data collected from privately and publicly insured patients Similar results were
found in other countries Phanthunane Whiteford Vos Bertram (2012) estimated from data
collected in 2008 that schizophreniarsquos financial impact in Thailand was 925 million USD
Magalore amp Knapp (2007) estimated schizophreniarsquos cost to be 67 billion pounds in England for
the 20042005 year It should be noted that in all three studies indirect costs consisted the
majority of the financial impact Wu et al (2005) only attributed 225 billon USD of direct costs
associated to the disease in term of medications treatments and else while Magalore amp Knapp
(2007) attributed 2 billion of the financial costs of the disease to direct cost Phanthumane et al
(2012) said that unemployment was the biggest culprit in the total financial costs in Thailand
It is possible to predict someonersquos risk The most well-known way to predict the risk of
schizophrenia in individuals is through their family history Indeed it has been shown that
schizophrenia has a strong genetic component While the general population lifetime risk to
develop schizophrenia is less than 1 children whose at least one of their parents has
schizophrenia have a 13 chance to develop it too (McGuffin Gottesman Farmer 1987) The
risk is higher in fraternal and identical twins with a 17 and 48 risk respectively (Mc
Gruffin et al 1987)
Furthermore schizophrenia and other psychotic disorders are part of the psychotic
spectrum The psychotic spectrum refers to the continuum of distressing or non-distressing
Discrimination Race Gender amp APPS 6
subclinical psychotic symptoms experienced by the general population that may in turn progress
to the full blown clinical symptoms diagnosed in psychotic disorders ((Dhossche et al 2002
Hanssen et al 2005 Wiles et al 2006 Dominguez et al 2011) In other words the diagnosis of
prodromal symptoms in an individual does not mean he will be psychotic in the future As a
matter of fact subclinical psychotic symptoms are actually common in the general population A
recent systematic meta-analysis found a median prevalence of 5 and a median incidence rate of
3 for prodromal psychotic symptoms and 75-90 of those symptoms disappeared over time
(van Os Linscott Myin-Germeys Delespaul and Krabbendam 2009) To reflect the uncertain
transient nature of subclinical psychotic symptoms a group of researchers proposed the term at
ldquorisk for mental staterdquo to imply that the individuals in the early phase of the disorder may never
fully develop the disorder They preferred their term to the word ldquoprodromerdquo which they stated
was a medical term that refers to the early signs of a disease and therefore alluded that the
disease will soon follow up (Yung et al p286) Indeed ldquofalse false positiverdquo individuals are
people who ldquowould have the same vulnerability markers as the true positives who do progress
from an at-risk mental state to psychosis but because of resilience or protective factors do not
make the transitionrdquo ( Yung et al 1996 p 288) Only a small amount of people with prodromal
symptoms makes the conversion to psychosis Yung et al (1996) found that only 212 of their
small sample (N=33) of at-risk for psychosis patients transitioned within 12 months In another
study about 40 of the high risk patients transitioned to clinical psychotic disorders within 12
months (Yung et al 1998)
The development of subclinical psychosis and its transition to clinical psychosis is
dependent on many factors After determining the amount of patients who transitioned to
psychosis Yung et al (2003) determined what were the highly predictors of psychosis of their
Discrimination Race Gender amp APPS 7
sample (N=49) They have found that individuals who have been experiencing the prodromal
symptoms for a long amount of time before diagnosis who were functioning poorly at intake and
expressed severe psychotic symptoms were at a significant risk to transition to psychosis
Subsequently the risk factors associated with the developing schizophrenia are the same as for
developing its milder symptoms Van Os et al (2009) did a systematic review of 1558 papers
published in the past 5 years at the time of the publication of their article They reported the same
risk of developing schizophrenia were also in its prodromal symptoms We can infer from those
information that the development of subclinical psychosis is heavily dependent onersquos level of
exposure to psychotic risk factors (van Os et al 2009) which in turn may transition to clinical
psychosis due to the length and severity of the symptoms experienced causing a decrease in the
level of functioning in the individual (Yung et al 1998)
Diagnosis of Subclinical Psychotic Symptoms
There are many instruments that can be used to diagnose prodromal symptoms in
individuals and the Structured Interview for Prodromal Syndromes (SIPS) is one of those
instruments (McGlasan et al 2001 Miller et al 2003 Rosen et al 2002 Miller et al 1999) A
trained professional expecting to use the SIPS will find the following measures the scale of
prodromal symptoms (SOPS) the schizotypal Personality Disorder Checklist based on the DSM
IV the family history questionnaire and the global assessment of functioning scale (Miller et al
2003) The family history section assesses the patientrsquos socio-demographic background
Information regarding a personal or family history of psychosis trauma and substance use is also
gathered there The Schizotypal personality disorder assesses the presence of the disorder in the
patient Five or more of the symptoms as listed in the DSM IV must be met for a full diagnosis
The SOPS is a 19 item questionnaire used to assess the severity onset and frequency of
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 4
such as losing contact with friends which results in their own isolation also known as
asociability They experience less pleasure and express less expression emotion known as
blunted effect and anhedonia
Disorganized thinking refers to onersquos incoherent and incomprehensible speech pattern
Grossly disorganized or abnormal motor behavior refers to onersquos inability to conform to
community standards Those behaviors are varied One group of such behaviors catatonia for
example is defined by a ldquomarked decrease in reactivity to the environmentrdquo (APA 2013 p 88)
Catatonic behaviors can be a ldquoresistance to instructions or negativismrdquo the ldquomaintenance of a
rigid or inappropriate posturerdquo known as mutism the ldquocomplete lack of verbal and motor
responsesrdquo known as stupor finally ldquopurposeless and excessive motor activity without obvious
causesrdquo also known as catatonic excitement (APA 2013 p 88) But abnormal motor behaviors
can also be very ldquochildlike to unpredictable agitationrdquo that may interfere with their daily
activities (APA 2013 p 88)
Schizophrenia and the psychotic spectrum
Schizophrenia is a brain disorder that ldquoinvolves a range of emotional cognitive and
behavioral dysfunctionsrdquo (APA 2013 p 99) According to the 5th and latest edition of the
diagnostic statistical manual for mental disorders (APA 2013) the diagnostic criteria belonging
to schizophrenia are as follow the patient should exhibit symptoms belonging to two or more of
the psychotic domains for a significant amount of time during a 1 month period At least 6
months of marked decrease in level of functioning in one or more major areas like work or
interpersonal relationships should be present Finally none of the symptoms can be explained by
any other disorders Persecutory delusions and auditory hallucinations are the two most
Discrimination Race Gender amp APPS 5
commons schizophrenic symptoms (Sartorius Shapiro Jablonksy 1974) Currently in the
United States about 03 to 07 of the population suffers from schizophrenia (APA 2013)
Schizophrenia is surprisingly a very costly disease In the year 2002 in the United States
Wu et al (2005) estimated that schizophreniarsquos financial impact to be at 627 billion US dollars
(USD) from data collected from privately and publicly insured patients Similar results were
found in other countries Phanthunane Whiteford Vos Bertram (2012) estimated from data
collected in 2008 that schizophreniarsquos financial impact in Thailand was 925 million USD
Magalore amp Knapp (2007) estimated schizophreniarsquos cost to be 67 billion pounds in England for
the 20042005 year It should be noted that in all three studies indirect costs consisted the
majority of the financial impact Wu et al (2005) only attributed 225 billon USD of direct costs
associated to the disease in term of medications treatments and else while Magalore amp Knapp
(2007) attributed 2 billion of the financial costs of the disease to direct cost Phanthumane et al
(2012) said that unemployment was the biggest culprit in the total financial costs in Thailand
It is possible to predict someonersquos risk The most well-known way to predict the risk of
schizophrenia in individuals is through their family history Indeed it has been shown that
schizophrenia has a strong genetic component While the general population lifetime risk to
develop schizophrenia is less than 1 children whose at least one of their parents has
schizophrenia have a 13 chance to develop it too (McGuffin Gottesman Farmer 1987) The
risk is higher in fraternal and identical twins with a 17 and 48 risk respectively (Mc
Gruffin et al 1987)
Furthermore schizophrenia and other psychotic disorders are part of the psychotic
spectrum The psychotic spectrum refers to the continuum of distressing or non-distressing
Discrimination Race Gender amp APPS 6
subclinical psychotic symptoms experienced by the general population that may in turn progress
to the full blown clinical symptoms diagnosed in psychotic disorders ((Dhossche et al 2002
Hanssen et al 2005 Wiles et al 2006 Dominguez et al 2011) In other words the diagnosis of
prodromal symptoms in an individual does not mean he will be psychotic in the future As a
matter of fact subclinical psychotic symptoms are actually common in the general population A
recent systematic meta-analysis found a median prevalence of 5 and a median incidence rate of
3 for prodromal psychotic symptoms and 75-90 of those symptoms disappeared over time
(van Os Linscott Myin-Germeys Delespaul and Krabbendam 2009) To reflect the uncertain
transient nature of subclinical psychotic symptoms a group of researchers proposed the term at
ldquorisk for mental staterdquo to imply that the individuals in the early phase of the disorder may never
fully develop the disorder They preferred their term to the word ldquoprodromerdquo which they stated
was a medical term that refers to the early signs of a disease and therefore alluded that the
disease will soon follow up (Yung et al p286) Indeed ldquofalse false positiverdquo individuals are
people who ldquowould have the same vulnerability markers as the true positives who do progress
from an at-risk mental state to psychosis but because of resilience or protective factors do not
make the transitionrdquo ( Yung et al 1996 p 288) Only a small amount of people with prodromal
symptoms makes the conversion to psychosis Yung et al (1996) found that only 212 of their
small sample (N=33) of at-risk for psychosis patients transitioned within 12 months In another
study about 40 of the high risk patients transitioned to clinical psychotic disorders within 12
months (Yung et al 1998)
The development of subclinical psychosis and its transition to clinical psychosis is
dependent on many factors After determining the amount of patients who transitioned to
psychosis Yung et al (2003) determined what were the highly predictors of psychosis of their
Discrimination Race Gender amp APPS 7
sample (N=49) They have found that individuals who have been experiencing the prodromal
symptoms for a long amount of time before diagnosis who were functioning poorly at intake and
expressed severe psychotic symptoms were at a significant risk to transition to psychosis
Subsequently the risk factors associated with the developing schizophrenia are the same as for
developing its milder symptoms Van Os et al (2009) did a systematic review of 1558 papers
published in the past 5 years at the time of the publication of their article They reported the same
risk of developing schizophrenia were also in its prodromal symptoms We can infer from those
information that the development of subclinical psychosis is heavily dependent onersquos level of
exposure to psychotic risk factors (van Os et al 2009) which in turn may transition to clinical
psychosis due to the length and severity of the symptoms experienced causing a decrease in the
level of functioning in the individual (Yung et al 1998)
Diagnosis of Subclinical Psychotic Symptoms
There are many instruments that can be used to diagnose prodromal symptoms in
individuals and the Structured Interview for Prodromal Syndromes (SIPS) is one of those
instruments (McGlasan et al 2001 Miller et al 2003 Rosen et al 2002 Miller et al 1999) A
trained professional expecting to use the SIPS will find the following measures the scale of
prodromal symptoms (SOPS) the schizotypal Personality Disorder Checklist based on the DSM
IV the family history questionnaire and the global assessment of functioning scale (Miller et al
2003) The family history section assesses the patientrsquos socio-demographic background
Information regarding a personal or family history of psychosis trauma and substance use is also
gathered there The Schizotypal personality disorder assesses the presence of the disorder in the
patient Five or more of the symptoms as listed in the DSM IV must be met for a full diagnosis
The SOPS is a 19 item questionnaire used to assess the severity onset and frequency of
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 5
commons schizophrenic symptoms (Sartorius Shapiro Jablonksy 1974) Currently in the
United States about 03 to 07 of the population suffers from schizophrenia (APA 2013)
Schizophrenia is surprisingly a very costly disease In the year 2002 in the United States
Wu et al (2005) estimated that schizophreniarsquos financial impact to be at 627 billion US dollars
(USD) from data collected from privately and publicly insured patients Similar results were
found in other countries Phanthunane Whiteford Vos Bertram (2012) estimated from data
collected in 2008 that schizophreniarsquos financial impact in Thailand was 925 million USD
Magalore amp Knapp (2007) estimated schizophreniarsquos cost to be 67 billion pounds in England for
the 20042005 year It should be noted that in all three studies indirect costs consisted the
majority of the financial impact Wu et al (2005) only attributed 225 billon USD of direct costs
associated to the disease in term of medications treatments and else while Magalore amp Knapp
(2007) attributed 2 billion of the financial costs of the disease to direct cost Phanthumane et al
(2012) said that unemployment was the biggest culprit in the total financial costs in Thailand
It is possible to predict someonersquos risk The most well-known way to predict the risk of
schizophrenia in individuals is through their family history Indeed it has been shown that
schizophrenia has a strong genetic component While the general population lifetime risk to
develop schizophrenia is less than 1 children whose at least one of their parents has
schizophrenia have a 13 chance to develop it too (McGuffin Gottesman Farmer 1987) The
risk is higher in fraternal and identical twins with a 17 and 48 risk respectively (Mc
Gruffin et al 1987)
Furthermore schizophrenia and other psychotic disorders are part of the psychotic
spectrum The psychotic spectrum refers to the continuum of distressing or non-distressing
Discrimination Race Gender amp APPS 6
subclinical psychotic symptoms experienced by the general population that may in turn progress
to the full blown clinical symptoms diagnosed in psychotic disorders ((Dhossche et al 2002
Hanssen et al 2005 Wiles et al 2006 Dominguez et al 2011) In other words the diagnosis of
prodromal symptoms in an individual does not mean he will be psychotic in the future As a
matter of fact subclinical psychotic symptoms are actually common in the general population A
recent systematic meta-analysis found a median prevalence of 5 and a median incidence rate of
3 for prodromal psychotic symptoms and 75-90 of those symptoms disappeared over time
(van Os Linscott Myin-Germeys Delespaul and Krabbendam 2009) To reflect the uncertain
transient nature of subclinical psychotic symptoms a group of researchers proposed the term at
ldquorisk for mental staterdquo to imply that the individuals in the early phase of the disorder may never
fully develop the disorder They preferred their term to the word ldquoprodromerdquo which they stated
was a medical term that refers to the early signs of a disease and therefore alluded that the
disease will soon follow up (Yung et al p286) Indeed ldquofalse false positiverdquo individuals are
people who ldquowould have the same vulnerability markers as the true positives who do progress
from an at-risk mental state to psychosis but because of resilience or protective factors do not
make the transitionrdquo ( Yung et al 1996 p 288) Only a small amount of people with prodromal
symptoms makes the conversion to psychosis Yung et al (1996) found that only 212 of their
small sample (N=33) of at-risk for psychosis patients transitioned within 12 months In another
study about 40 of the high risk patients transitioned to clinical psychotic disorders within 12
months (Yung et al 1998)
The development of subclinical psychosis and its transition to clinical psychosis is
dependent on many factors After determining the amount of patients who transitioned to
psychosis Yung et al (2003) determined what were the highly predictors of psychosis of their
Discrimination Race Gender amp APPS 7
sample (N=49) They have found that individuals who have been experiencing the prodromal
symptoms for a long amount of time before diagnosis who were functioning poorly at intake and
expressed severe psychotic symptoms were at a significant risk to transition to psychosis
Subsequently the risk factors associated with the developing schizophrenia are the same as for
developing its milder symptoms Van Os et al (2009) did a systematic review of 1558 papers
published in the past 5 years at the time of the publication of their article They reported the same
risk of developing schizophrenia were also in its prodromal symptoms We can infer from those
information that the development of subclinical psychosis is heavily dependent onersquos level of
exposure to psychotic risk factors (van Os et al 2009) which in turn may transition to clinical
psychosis due to the length and severity of the symptoms experienced causing a decrease in the
level of functioning in the individual (Yung et al 1998)
Diagnosis of Subclinical Psychotic Symptoms
There are many instruments that can be used to diagnose prodromal symptoms in
individuals and the Structured Interview for Prodromal Syndromes (SIPS) is one of those
instruments (McGlasan et al 2001 Miller et al 2003 Rosen et al 2002 Miller et al 1999) A
trained professional expecting to use the SIPS will find the following measures the scale of
prodromal symptoms (SOPS) the schizotypal Personality Disorder Checklist based on the DSM
IV the family history questionnaire and the global assessment of functioning scale (Miller et al
2003) The family history section assesses the patientrsquos socio-demographic background
Information regarding a personal or family history of psychosis trauma and substance use is also
gathered there The Schizotypal personality disorder assesses the presence of the disorder in the
patient Five or more of the symptoms as listed in the DSM IV must be met for a full diagnosis
The SOPS is a 19 item questionnaire used to assess the severity onset and frequency of
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 6
subclinical psychotic symptoms experienced by the general population that may in turn progress
to the full blown clinical symptoms diagnosed in psychotic disorders ((Dhossche et al 2002
Hanssen et al 2005 Wiles et al 2006 Dominguez et al 2011) In other words the diagnosis of
prodromal symptoms in an individual does not mean he will be psychotic in the future As a
matter of fact subclinical psychotic symptoms are actually common in the general population A
recent systematic meta-analysis found a median prevalence of 5 and a median incidence rate of
3 for prodromal psychotic symptoms and 75-90 of those symptoms disappeared over time
(van Os Linscott Myin-Germeys Delespaul and Krabbendam 2009) To reflect the uncertain
transient nature of subclinical psychotic symptoms a group of researchers proposed the term at
ldquorisk for mental staterdquo to imply that the individuals in the early phase of the disorder may never
fully develop the disorder They preferred their term to the word ldquoprodromerdquo which they stated
was a medical term that refers to the early signs of a disease and therefore alluded that the
disease will soon follow up (Yung et al p286) Indeed ldquofalse false positiverdquo individuals are
people who ldquowould have the same vulnerability markers as the true positives who do progress
from an at-risk mental state to psychosis but because of resilience or protective factors do not
make the transitionrdquo ( Yung et al 1996 p 288) Only a small amount of people with prodromal
symptoms makes the conversion to psychosis Yung et al (1996) found that only 212 of their
small sample (N=33) of at-risk for psychosis patients transitioned within 12 months In another
study about 40 of the high risk patients transitioned to clinical psychotic disorders within 12
months (Yung et al 1998)
The development of subclinical psychosis and its transition to clinical psychosis is
dependent on many factors After determining the amount of patients who transitioned to
psychosis Yung et al (2003) determined what were the highly predictors of psychosis of their
Discrimination Race Gender amp APPS 7
sample (N=49) They have found that individuals who have been experiencing the prodromal
symptoms for a long amount of time before diagnosis who were functioning poorly at intake and
expressed severe psychotic symptoms were at a significant risk to transition to psychosis
Subsequently the risk factors associated with the developing schizophrenia are the same as for
developing its milder symptoms Van Os et al (2009) did a systematic review of 1558 papers
published in the past 5 years at the time of the publication of their article They reported the same
risk of developing schizophrenia were also in its prodromal symptoms We can infer from those
information that the development of subclinical psychosis is heavily dependent onersquos level of
exposure to psychotic risk factors (van Os et al 2009) which in turn may transition to clinical
psychosis due to the length and severity of the symptoms experienced causing a decrease in the
level of functioning in the individual (Yung et al 1998)
Diagnosis of Subclinical Psychotic Symptoms
There are many instruments that can be used to diagnose prodromal symptoms in
individuals and the Structured Interview for Prodromal Syndromes (SIPS) is one of those
instruments (McGlasan et al 2001 Miller et al 2003 Rosen et al 2002 Miller et al 1999) A
trained professional expecting to use the SIPS will find the following measures the scale of
prodromal symptoms (SOPS) the schizotypal Personality Disorder Checklist based on the DSM
IV the family history questionnaire and the global assessment of functioning scale (Miller et al
2003) The family history section assesses the patientrsquos socio-demographic background
Information regarding a personal or family history of psychosis trauma and substance use is also
gathered there The Schizotypal personality disorder assesses the presence of the disorder in the
patient Five or more of the symptoms as listed in the DSM IV must be met for a full diagnosis
The SOPS is a 19 item questionnaire used to assess the severity onset and frequency of
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 7
sample (N=49) They have found that individuals who have been experiencing the prodromal
symptoms for a long amount of time before diagnosis who were functioning poorly at intake and
expressed severe psychotic symptoms were at a significant risk to transition to psychosis
Subsequently the risk factors associated with the developing schizophrenia are the same as for
developing its milder symptoms Van Os et al (2009) did a systematic review of 1558 papers
published in the past 5 years at the time of the publication of their article They reported the same
risk of developing schizophrenia were also in its prodromal symptoms We can infer from those
information that the development of subclinical psychosis is heavily dependent onersquos level of
exposure to psychotic risk factors (van Os et al 2009) which in turn may transition to clinical
psychosis due to the length and severity of the symptoms experienced causing a decrease in the
level of functioning in the individual (Yung et al 1998)
Diagnosis of Subclinical Psychotic Symptoms
There are many instruments that can be used to diagnose prodromal symptoms in
individuals and the Structured Interview for Prodromal Syndromes (SIPS) is one of those
instruments (McGlasan et al 2001 Miller et al 2003 Rosen et al 2002 Miller et al 1999) A
trained professional expecting to use the SIPS will find the following measures the scale of
prodromal symptoms (SOPS) the schizotypal Personality Disorder Checklist based on the DSM
IV the family history questionnaire and the global assessment of functioning scale (Miller et al
2003) The family history section assesses the patientrsquos socio-demographic background
Information regarding a personal or family history of psychosis trauma and substance use is also
gathered there The Schizotypal personality disorder assesses the presence of the disorder in the
patient Five or more of the symptoms as listed in the DSM IV must be met for a full diagnosis
The SOPS is a 19 item questionnaire used to assess the severity onset and frequency of
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 8
psychotic symptoms in the patients When investigating the presence or non-presence of
symptoms in positive negative disorganized and general symptoms a trained professional rates
the items on a 0 to 6 point scale along with their frequency and date of onset A score of 0-2
means that symptoms are normal or absent A score of 3-5 means that the symptoms are
prodromal and a score of 6 means psychotic Of course a trained professional should always
note of the onset of the symptoms and indicate whether they have aggravated in the last 12
months (McGlashanWalshWood 2010) The Global Assessment of functioning assesses the
level of functioning of the patient over the past 12 months The assessment is scored on 10
categories of 10 scores ranging from 1 to 100 The patient receives two score based on its present
and 12 month prior level of functioning (McGlashanWalshWood 2010)
After the interview information gathered on the measures is analyzed based on two main
criteria the presence of psychotic syndrome (POPS) and the Criteria of psychosis risk
syndromes (COPS) (Miller et al 2003 Miller et al 2010) On the one hand the Information
meeting POPS criteria mean that the individual has been experiencing symptoms for a while and
currently meet the criteria for psychosis On the other hand informationrsquos meeting COPSrsquo
criteria can be categorized in one of the following three categories brief intermittent psychotic
symptom (BIPS) attenuated positive symptom (APPS) and genetic risk and deterioration
(GRD) All three symptom categories were first identified by Yung et al (1996 1998) Miller et
al (2003) defines each COPS symptom as follow BIPS is defined by the psychotic symptoms
have been experienced in the past three months but are too brief and too infrequent to be
considered at risk for a full psychosis syndrome GRD is for individuals who experienced a 30
decreased in GAF scored meet the criteria for schizotypal personality disorder or have a first
relative who has the disorder APPS is defined by the mild positive psychotic symptoms that
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 9
occurred at least once a week in the past month and which severity have worsened in the past
year that put the patient at risk to form a fully diagnosable psychotic disorder The SIPS was
modeled after Yung et al criteria of prodromal psychotic symptoms (Miller et al 1999) A
validity study found that 50 of prodromal patients who were diagnosed with the SIPS
transitioned to clinical psychosis within a 12 month period of time (Miller et al 2003)
Schizophrenia Gender and Prodromal phase
Extensive research on schizophrenia revealed some definitive gender differences in terms
of characteristics of the disorder such as age of onset premorbid condition symptomatology
characteristics course of illness and comorbidity of substance use (Ochea S Usall J Labad
X Kulkarni J 2012) An earlier age of onset is seen in men but seems to disappear in the
presence of family history in schizophrenia (Goldstein Tsuang Faraone 1989 Gureje 1991
Galderisi bucci Ucok Peuskens 2011 Ochoa et al 2006 Albus et al 1994 Peraumllauml
Kuoppasalami Partonen Kieseppauml 2007) For example Galderisi et al (2011) found the age of
onset in men was around 22 years and around 24 years in women Men report a higher
comorbidity of cannabis alcohol cocaine and hallucinogen use than women (Galderisi et
al2011 Cotton et al 2009 Wade Harrigan Edwards Burgess Whelan McGorry 2006 Foti
Kotov Guey Bromet 2010 Rodriguez-Jimenez et al 2008) Also while many studies did not
find gender differences in symptomatology (Addington Addington Patten 1996 Lindstrom
Knorring 1994 Hayashi Igarashi Yamashina Sunda 1995) those that did find a difference
reported more negative and disorganization symptoms in men than women (Galderisi et al
2011 Morgan Castle Jablensky 2008 Abel Drake Goldstein 2010) Women are found to
have had better premorbid condition and course of illness than men (Shatasel Gur Gallacher
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 10
Heimberg Gur1992 Morgan Castle Jablensky 2008Uggerby Nielsen Correll Nielsen 2011
Usall Araya Ochoa Busquets gost Marquez 2001)
Yet it is widely regarded that no gender difference exists in the prevalence of
schizophrenia (Mc Grath Saha Chant Welham 2008 Saha Chant welham Mc Grath 2005)
Indeed Mc Grath et al (2008) conducted a meta-analysis of 383 studies in regard to prevalence
incidence and mortality risks and found no gender difference in the prevalence of schizophrenia
But he and his team (2008) found a 14 male to female rate ratio in the incidence of
schizophrenia Such results were consistent with other research also demonstrating a higher
incidence of schizophrenia in men (Saha Chant welham Mc Grath 2005 Alerman Kahn
Selten 2003 Abel Drake Goldstein 2010) Furthermore the number of research finding a
higher male incidence in schizophrenia vastly outnumber those studies that find the inverse (Mc
Grath Saha Welham Saadi MacCauley amp Chant 2004)
An attempt at understanding such discrepancy in the research could be made by looking
at the definition of the two words According to Mc Grath et al (2008) incidence measures the
amount of new cases of a disorder in a population during a specific period of time while
prevalence relates to the measure of proportion ldquoof surviving individuals who manifest a disorder
at a specific time or during a specific periodrdquo (p68) From the definition of the words a higher
mortality risk in men seems to be the answer to the discrepancy For example Galderisi et al
(2012) found that males significantly abuse alcohol more than women Rodriguez-Jimenez et al
(2008) found a higher consumption of cocaine and hallucinogen and cannabis in men While
women are more likely to attempt suicide (Austad Joa Johannessen Larsen 2013) men are
more likely to succeed in their suicide attempt (Test Burke Wallisch 1990 Silvia 2010) But
Mc Grath et al (2008) seem to refute such hypothesis by reporting that they did not find a sex
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 11
difference in the mortality risk for all causes of mortality More research is needed to determine
if health related issues in regard to substance use and suicide risk are enough in explaining the
discrepancy in the gender difference in incidence and in prevalence research
In the prodromal phase very few studies have looked at the gender difference in
incidence premorbid condition and so on Of those studies results found so far are mixed As it
was explained previously psychosis is part of a spectrum In other words gender difference
found in clinical psychotic disorders should also be found in subthreshold symptoms It is with
this assumption that Barajas Ochoa Obiols Lulucats-jo (2015) decided to conduct a literature
review on the gender difference in at-risk individuals They were able to find only 12 studies
Some of those studies results were consistent with gender differences in clinical psychosis some
were not Results that are consistent with current gender research in psychosis are that men
exhibit more severe negative symptoms worst level of functioning than women (Barajas et al
2015) While women receive more social support and exhibited more affective symptoms than
men (Barajas et al 2015) In terms of incidence Barajas et al (2015) found some studies that
show a higher male to female incidence (eg Von Os et al 2009) others found the inverse or no
difference Due to the low amount studies examined Barajas et al (2015) said that their results
could not be generalized
Race amp Psychosis
Many studies have shown that ethnic minorities especially blacks living in
predominantly white developed countries are at a higher psychosis risk (Fearon et al 2006
Bhugra et al 1997 Mc Neil 2005 Hutchinson et al 1996 Spronton amp Nazroo 2002 Sohler amp
Bromet 2003 Bresnahan et al 2007 Johns amp Von OS 2000) Three large sample incidence
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 12
and prevalence studies from UK and the US illustrate the high risk for psychosis in ethnic
minority groups The Aetiology and Ethnicity of Schizophrenia and Other Psychosis (AESOP)
was a study conducted by Fearon et al (2006) across three psychiatric centers in the UK for two
years The study examined the psychotic incidence rate for different ethnic groups (N=568) with
an age range of 16 to 54 Potential participants could only participate to the study once and
should exhibit psychotic symptoms in delusions hallucinations thought disorders and negative
symptoms that characterized them as at-risk individuals (Fearon et al 2006) Participants also
identified themselves as African-Caribbean Black African Asian Mixed White British and
white other The results show that when adjusted for sex and age all the categorical groups were
at an increased incidence rate ratio (IRR) for psychosis compared to white British But the IRR
for psychosis in Black Caribbean (67 95 confidence interval (CI) = 54-84) and Black
African ( 41 CI=32-53) were the highest in comparison to white British Two things can be
inferred from this study The first is that being an immigrant is linked to an increase risk of
developing schizophrenia The second is that being a black immigrant makes you more likely
than the rest of the population to develop psychotic symptoms
The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) is a
community-based prevalence study in the UK that was conducted by Spronton amp Nazroo (2002)
The different ethnic groups of the study were Indian Pakistani Bangladeshi Black Caribbean
Irish and White British Researchers calculated the age-adjusted risk ratio of different ethnic
groups (N=4281) They found that African Caribbean were at a higher odds (184 CI= 111-
303) of expressing psychotic symptoms than whites Similarly as AESOP onersquos race and
minority status matter in the development of psychosis The difference to the AESOP study is
that the risk here is milder and only one ethnic black group was examined
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 13
In the US Breshnan et al (2007) looked at the incidence rate of schizophrenia for
African American and white in birth cohort To be eligible for the study the participantrsquos mother
should have been enrolled during pregnancy at the Alemada County Kaiser Permanente Medical
Care Plan clinics between the years 1956-1966 Only one offspring per family was allowed to
participate in order to eliminate siblingsrsquo correlated observations (Breshman et al 2007)
Selected participants (N=6636) were followed during the years 1981-1997 The results found
that African-American were two times more likely to develop schizophrenia than white after
adjustment for socio-demographic variables (Breshman et al 2007) Breshman et al (2007) is
one the few incidence studies in psychosis conducted in the US The fact that the participants and
their mothers are US-born put this study at a significant advantage over the other two It allows
to look at the risk to develop schizophrenia based solely on race From what we see just like in
other two studies being black constitutes a significant risk factor in relation to schizophrenia
which further support that minorities are in increased risk of psychosis
Unsurprisingly the risk for psychosis decreases when an ethnicity is no longer a minority
(Bhugra et al 2000 Hickling amp Rodgers-Johnson 1995 Mahy et al 1999 Boydell et al 2001)
First-onset studies for psychosis that were conducted in Trinidad (Bhurga et al 1996) Jamaica
(Hickling amp Robertss-Johnson 1995) and Barbados (Mahy et al 1999) found similar incidence
rate ratio across them (236 in Jamaica 32 in Barbados and 22 in Trinidad) Those rates are
much lower than the ones found in African Caribbean living in the UK (Mahy et al 1999 Fearon
et al 2006) Velinget al (2008) found that immigrants living in low-ethnic density
neighborhood were at significantly increased adjusted rate ratio for psychosis (236) than those
who live in neighborhood with high-ethnic density neighborhood (136) Boydell et al (2001)
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 14
found that black individuals living in neighborhood where they were a minority were at a higher
risk of schizophrenia than those who lived in neighborhood where they were better represented
Racial discrimination psychosis amp Black
According to Cater (2007) racial discrimination is a type of racism which role is to create
a distance whether intentionally or not between the dominant racial group members and the
minority racial groups through behaviors thoughts policies and strategies Following this
definition it is logical to infer that racial discrimination can be experienced in a wide range of
real life setting as long as it enables members of the dominant group to ostracize minorities That
is why the self-report questionnaire Experiences of Discrimination (EOD) (Krieger Smith
Naishadam HartmanBadeau 2005) ask both the place and the frequency where discrimination
is experienced People can be discriminated at work school hospital courts and other places
overtly or perniciously
The discrimination that someone receives may be gender-specific Sexism is the word
used for discrimination to the opposite-sex Although the word gives the impression of going
both ways it is mostly expressed toward women After all discrimination is mostly expressed by
the dominant group and in the US men are the dominant sex For example women may be
barred from specific position or income because of their gender a process known as the glass
ceiling The US census Bureau (2011) reported that women in general earn 23 percent less than
men in 2010
Sexism is worse in ethnic minorities Women from ethnic minorities have to deal with
negative perceptions related to their raceethnicities along with negative perceptions related to
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 15
their gender leaving them extremely disadvantaged In the same income example presented
before women typically earn less than their men counterpart within the same raceethnicity
African American women earn 111 percent less than African American men Hispanic women
earn 223 percent less than Hispanic men and Asian Women earn 87 percent less than Asian
men (US census Bureau 2011)
Once experienced racial discrimination is highly personal and painful (Delgado 1982
Landrine amp Klonoff 1996) and can lead to a series of negative physical psychological
responses and even worse health behaviors in the individual (Pascoe amp Richman 2009 William
amp Mohammad 2009 Brown et al 2000 Krieger et al 2013) Black individuals who
experienced discrimination are more likely to exhibit psychological distress anxiety depression
than those who do not experience discrimination (eg Brown et al 2000) In turn the
consequences of racial discrimination differ based on gender Black women who experience
discrimination are more likely than men to express symptoms of depression and psychological
distress (eg Brown et al 2000 Lambert English amp Ialongo 2014)
In the literature racial discrimination represents a major link between the risk of
psychosis and the ethnic minority status of an individual For example Anglin Lighty
Greenspoon and Ellman (2014) conducted a series of self-report questionnaires based on
attenuated Psychotic Positive Syndromes (APPS) discrimination depression and anxiety among
a US based young adults ethnic minorities population (N=650) Participants self-identified as
Hispanic Asian Black White and other They reported that ethnic minorities endorsed racial
discrimination more than white in the sample They also found that racial discrimination was
associated with all of the domains of APPS and individuals exposed to racial discrimination were
more likely to endorsed eight or more distressing APPS symptoms meaning that they are likely
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 16
to be at a high risk for psychosis (Anglin et al 2014) In a follow up study to the EMPIRIC
study they found that discriminatory exposure to racist insults (odd ration (OR=23 95
CI=14- 34 plt0001) and unfair treatment at work (OD=21 CI=13-34 P=0004) put someone
at the highest risk of mental disorders Black individuals in particular were at increased risk of
mental disorders when they were unfairly treated at work (OD=29 CI=12-73 p=002) (Bhui et
al 2005)
In addition the frequency with which someone is exposed to discriminatory situations is
also an important link to psychosis Veling Selten Susser Laan Mackenbach Hoek (2007)
conducted a study in the Netherlands on different ethnic minorities They found that the risk for
psychosis was positively linked to the level (very low low medium high) of perceived
discrimination reported among ethnic minorities (Veling et al 2007) For example a very low
report of discrimination was associated with an incidence rate ratio (IRR) of psychosis equals to
12 (CI=081-190) after adjustment for age and gender While a high report of discrimination
was associated with an IRR = 400 (CI=300-535)
Current Study
We know so far that psychosis is a spectrum that shares the same risk factors regardless if
itrsquos clinically diagnosed or still in its sub-threshold stage (Von Os et al 2009) At least in the
level of clinical psychosis convincing gender differences were found in serval aspects of the
disorder The rate ratio of men to women was 14 meaning that close to three men compared to
two women are newly clinically diagnosed for psychosis at any point in time (McGrath et al
2008) Ethnic minorities especially black individuals (Fearon et al 2006) are a population at a
higher risk to psychosis associated to the type and frequency of discrimination they are exposed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 17
to (Velin et al 2007 Bhui et al 2005) At the subthreshold level discrimination was associated
to APPS a category of prodromal symptoms for ethnic minorities (Anglin et al 2014)
Subsequently it can be inferred from the information presented above that first a women to
men difference in APPS should be present in blacks as long as it is sufficiently mediated by
discrimination since discrimination is a gendered experience secondly due to discrimination
such gender difference in APPS in the black group should be significantly higher than the ones
that may be found in white individuals
To test those assumptions we tested the following hypotheses
1- Black individuals will be more discriminated against than white individuals
2 We will find a gender difference in the discrimination reported by black individuals
3- A gender difference will be found in black individuals in the report of APPS
4- APPS will be higher in black than white individuals
5- Black individuals will be more likely to endorse high level of distressing positive
symptoms than white individuals
6- Discrimination will mediate the relation between APPS and gender in the black
population
Methods
Participants and Procedure
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 18
Our study sample was drawn from data collected from two large Northeast Universities
(N= 2539) Data collected from one of the universities was composed of primarily emerging
young adults (19 to 29 years old) from ethnic minorities Participants from this particular
university had to self-identify as African-AmericanBlack African Descent or as an immigrant
(first or second generation) in an online subject pool to maximize the number of young ethnic
minorities possessing characteristics of high psychosis risk (Anglin Lee Yang amp Opler 2010)
Data collected from the other university was non-selective of the undergraduate students
recruited from another online subject pool across various interdisciplinary courses All
Participants completed a series of self-report questionnaires in the laboratory computer of their
respective universities The protocol was approved by the institutional review board of each
university Participants signed written consent forms and received course credit for their
participation in the study For the purpose of the study only data from black and white
individuals were analyzed (N= 1633)
Measure
APPS To assess the Attenuated Positive Psychotic Symptoms (APPS) each participant
was required to complete the Prodromal Questionnaire-Likert ( PQ Likert) ( Loewy Bearden
JohnsonRaine amp Cannon 2005 Loewy Bearden amp Cannon 2007) which is a 92-item self-
report measure of subclinical psychotic symptoms experienced in the absence of alcohol drugs
and other medications Participants mentioned whether they had experienced the PQ items in the
past month and whether they found them distressing or not The PQ Likert is composed of four
subscales scores of which the positive symptoms (APPS) (45 items eg unusual thought content
and perceptual abnormalities) have been found to have the strongest predictive value (Loewy et
al 2005)
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 19
The PQ scale is not a clinical assessment tool However Loewy et al (2007) noted that
self-report questionnaires are reliable and valid Endorsing 8 or more of positive PQ items
predicted a SIPS diagnosis (prodromal or clinical) with 90 sensitivity and 49 specificity
(Loewy et al 2005) The endorsement of 8 or more distressing APPS in the PQ scale suggest
that the individual may be at a high risk of psychosis (Loewy et al 2007) For the purpose of
the study a dichotomous variable that compared High (8 or more positive symptoms) vs Low (4
or less positive symptoms) levels of endorsement of Distressing Positive PQ was created We
also created a dimensional variable to look at the score of number of APPS endorsed for each
participant (0-45)
Self-reported Experiences of Discrimination (EOD) were determined using the EOD
Instrument (Kriegeret al 2005) a questionnaire which assess the location of the experienced of
the discrimination and its frequency The nine locations assessed are as follow school getting a
job work getting medical care getting service in a store getting credit or a loan on the street
and from the police or the courts The frequency of occurrence of each situation was endorsed on
a three point scale by each participant (1-3) where 1 equates to once and 3 equates to four or
more times (Krieger et al 2005) Two new variables were created for our study First a
dimensional variable called ldquoEODfreqrdquo was created to get for each participant the sum all of
the frequencies of occurrence of experienced discrimination (0-27) The second variable was also
a dimensional variable called ldquoEODscalerdquo to get into a singular number the sum of all the
different discriminatory items domains endorsed by each participant (0-9)
Sociodemographic data Sociodemographic data collected from the participants were
their age (years) gender (female male) immigration status raceethnicity proficiency in
English Raceethnicity was determined in the question ldquochoose one category that best captures
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 20
how you see yourselfrdquo and given several options Responses were grouped into several
categories Black white Hispanic Asian Participants also say whether they were born in the
US or not A ldquoWhitevsblackrdquo binary was created for the purposes of our analyses where the
white group would serve as the reference group Black and white individuals were put in the
same categorical variable since only those two groups are of interest for our study Two other
variables combining gender and race were created A 4 level variable called ldquoracegenderrdquo was
created and contained the different combination of gender and race possible such as white male
white female black male black female Finally a ldquosexXrace interactionrdquo variable was created
by multiplying the variables whitevsblack and gender in order to look at the possible interaction
of sex and race on the endorsement of APPS
Statistical analyses
Mean groups differences in gender race and in gender in combination with each race
separately in the endorsement of PQ positive symptoms frequency and type of discrimination
were assessed using one factor and two factors ANOVA A crosstab Chi square of PQ levels
High vs Low by ldquoracegenderrdquo was performed in order to determine if there was a difference in
the endorsement of PQ positive distressing symptoms in the whole sample Lastly we did a two-
step linear regression analysis of APPS in terms of gender and EODfreq for the black population
of the sample to assess whether discrimination mediated the relation between race and gender in
regard to endorsement of APPS Gender was in in the first step while EODfreq was added in the
second step
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 21
Results
Sample characteristics
The overall demographic sample is described in Table 1 The majority of the sample was
female (729) white (686) and US born (875) The average age was 2021 (SD=204)
years old with a range of 18 to 29 years old Mean APPS was 41 (SD=566) with the majority
of the sample (719) endorsed one or more positive symptoms But mean APPS-distress
(M=172 SD=308) was lower with a majority (583) endorsing no distressing symptoms
In term of discrimination the mean of domain of discrimination reported was very low
(M=120 SD150) with 551 of our sample reporting one or more domains The mean of
frequency of discrimination was much higher (M=226 SD=319) with 548 of the sample
reporting to have been discriminated against at least once
APPS analyses
A two factor (2X2) ANOVA of race by gender in regard to endorsement of APPS
showed several significant results First there was a significant main effect of gender on the
amount of APPS endorsed F(11627)= 2051 plt0001 Males reported more APPS than
females Mdiff=147 95 confidence Interval (CI) (083 ndash 211) plt0001 There was also a
significant main effect of race on the amount of the APPS endorsed F (1 1627) = 18032
plt0001 Black endorsed more APPS than whites Mdiff= 436 95 Confidence Interval (CI)
(372 - 500) plt0001 There was a significant interaction between gender and race on the
amount of APPS endorsed F (11627)=803 plt0001 In order to interpret the significant
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 22
interaction 4 groups captured in the raceXgender interaction term were analyzed using one way
ANOVA
The One way ANOVA revealed a significant difference in APPS across the 4 racegender
groupings As expected from the two factor ANOVA there was main effect in the racegender
grouping (racegender) variable to the amount of APPS endorsed F(31627)=69505 plt0001All
the mean APPS to the racegender variable are reported in figure 1 Tukey post hoc test revealed
that Black males endorsed significantly more APPS than Black females (Mdiff=239 CI(098 ndash
38) plt0001) White males (Mdiff=528 CI (383 ndash 672) plt0001)) and White females
(Mdiff=583 CI (451 ndash 713) plt0001) It also revealed that Black females endorsed more APPS
than White males (Mdiff= 289 CI (186 ndash 391) plt0001) and White females( Mdiff= 344 CI
(260 ndash 428) plt0001) Finally White male endorsed slightly more APPS than white female
but it was not significant Mdiff= 055 95 CI (-3496-145) pgt005
Racegender and High vs Low endorsement of distressing APPS
A chi-square of ldquoracegenderrdquo by High vs low risk of psychosis shows a significant
relationship between the two X2(3 N=1520) =448 plt0001 Black females and males were
more likely to be in the high risk category (11 and 18 respectively) than white males and
females (27 and 48) See figure 2 for percentage of high and low endorsement of distressful
APPS for every combination of racegender
Racial Discrimination
See figure 3 for the complete report of the mean of frequency of discrimination for each
combination of racegender One way ANOVA of the racegender variable and frequency of
discrimination reported a main effect of the racegender variable on the frequency of
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 23
discrimination endorsed F (3 1627) = 16003 plt0001 Tukey post hoc test showed where the
significant differences lie Black males significantly endorsed a higher frequency of
discrimination than black females (Mdiff= 092 CI(021 ndash 165) p=0005) white female (Mdiff=
384 CI(316 ndash 451) plt0001 white male (Mdiff= 381 CI(307 ndash 455) plt0001) Black female
significantly endorsed a higher frequency of discrimination than white female (Mdiff= 291
CI( 248 ndash 334) plt0001) and white male (Mdiff= 289 CI(236 ndash 342) plt0001) White male
did not significantly endorse more frequency of discrimination than white female (Mdiff= 0020
CI(-044 ndash 048) pgt005)
Just like for frequency of discrimination the One way ANOVA analysis of racegender
and EODscale showed a main effect of racegender combination on the domain of
discrimination endorsed F (3 1627)= 20285 plt0001 Tukey post hoc test further clarified
where the difference lied Black males did not significantly endorse more domains of
discrimination than black female (Mdiff= 031 CI(-017 ndash 064) p=007) but did endorse more
domain of discrimination than white female (Mdiff= 186 CI(156 ndash 217) plt0001) and white
male (Mdiff= 186 CI(152 ndash 219) plt0001 It also showed that black female significantly
endorsed more domain of discrimination than white female (Mdiff= 155 CI (135 ndash 175)
plt0001) and white male (Mdiff= 154 CI(130 ndash 178) plt0001) White males had a negligible
and insignificant rise in endorsed domain of discrimination than white female (Mdiff= 0008 CI(-
022 ndash 020) pgt005) The complete mean of endorsed domain of discrimination for each
genderrace combination can be seen in figure 4
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 24
Frequency of Discrimination Black individuals and APPS
Two linear regression models were conducted to determine whether the effect of gender
on APPS in the Black subsample may be partly explained by exposure to racial discrimination
The first unadjusted model compared genderrsquos relation to APPS and found a significant relation
(b=239 standard error(se)= (075) p=0001) In the second model mean frequency of racial
discrimination was added to the unadjusted model and was significant (b=21 se (0077)
p=0005) Notably the beta coefficient for gender in this adjusted model was slightly decreased
but remained significant b=219 (se (0077) P=0003) Those results and more are reported in
table 2
Discussion
Aims
The study had two main aims first a women to men difference in APPS should be
present in blacks as long as it is sufficiently mediated by discrimination since discrimination is a
gendered experienced secondly due to discrimination such gender difference in APPS in the
black group should be significantly higher than the ones that may be found in white individuals
The first aim was partially supported by our results Black man reported a higher frequency of
discrimination more endorsement of APPS and more endorsement of distressing APPS than
black females (see fig 1 2 3 amp4) The two models of linear regression lines of frequency of
discrimination gender in the endorsement of APPS found a significant relation between
frequency of discrimination and the level of APPS reported However discrimination did not
mediate the relation of gender and race in the black population (see table 2)
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 25
Our second aim was also partially supported Black participants especially black males
endorsed more discrimination than white participants regardless of their gender (see fig 3 amp 4)
Subsequently Black participants especially black males reported a higher endorsement of
APPS and distressing APPS than white males and females participants However as reported in
the paragraph above discrimination is not the main link explaining those differences across race
Study implications
The gender difference in perceived discrimination reported by our black sample is in line
with the literature One might have expected black females to have reported more instance of
discrimination due to the dual effect of sexism and racism Black women have to deal with
certain discrimination in regard to their sexuality level of work intelligence femininity that
black men do not experience (Shorter-Gooden amp Jones 2003) But there are two main reasons
for our current results first discrimination needs to be recognized in order to be reported by an
individual second black men are more overtly discriminated against in the US Shorter-Gooden
amp Washington (1996) reported that race is more salient than gender in black individuals For
example in a series of survey that they conducted (Shorter-Gooden Jones 2003) among US
black women (N=333) only found 69 of them who reported at least one instance of
experienced discrimination Surprisingly when interviewed later many of the ones who did not
report an instance of discrimination shared personal discriminatory stories related to unequal
pay harassment sexual violence Shorter amp jones (2003) concluded that black women are not
sensitized enough to recognize those forms of discrimination Furthermore studies have shown
that black men are more frequently the target of racial stereotypes than females that picture them
as more threatening and violent (Krieger amp Sidney 1996 Williams amp Mohammed 2009)
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 26
Our results support the idea that there is a gender difference in risk of psychosis
especially in ethnic minorities (Ochoa et al 2008 Ochoa et al 2004 Alerman et al 2005
Veilin et al 2006) Ochoa et al (2008) found a higher incidence of schizophrenia in men than
women Our results showed men generally endorsed more APPS than women (Mdiff=147 95
confidence Interval (CI) (083 ndash 211) plt0001) Further analyses showed that race modified the
relationship between gender and APPS which is in line with Veling et al (2006) study in the
Netherlands In term of ethnicity Veling et al (2006) reported that Moroccan men second and
first generation immigrants were at an increased risk for schizophrenic disorders compared to
both Moroccan woman second and second generation and white Dutch irrespective of the
gender Similarly our results showed that black men endorsed more APPS than black female
(plt0001) white males (plt0001) and white female (Plt001) (see fig 1) Even white men
endorsed more APPS than females even though it was not significant (pgt005) (fig 1) Black
men were also more likely to endorse more distressing APPS than everyone else (see fig 2)
Veling et al (2006) reported Moroccan encounter great difficulties in their process of
acculturation such as more perceived discrimination social defeat and else Likewise our study
showed that black men are more discriminated against than anyone else in our sample (see fig 3)
Extraneous factors
Other factors must be working in sync with discrimination to produce the results found in
the study since it may only partially mediate the relation between race and gender in the black
subgroup A look at table 1 shows that a higher proportion of black (242) participants were
first generation immigrants than the white sample (72) Studies have shown that immigration
is an important risk factor in the development of psychotic disorders (eg Fearon et al 2006)
Both the AESOP and EMPIRIC studies showed that black immigrant groups were at higher
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 27
incidence rate ratio to develop schizophrenia than the white natives (Fearon et al 2006 Spronton
amp Nazroo 2002) Immigrants whether new or not have to handle a lot of stressful situation
such adapting to a new culture learning a new language lack of financial and social support and
even xenophobia The degree to which they adapt to their new environment is link to psychosis
(Vega Sribney Miskimen Escobar and Aguilar-Gaxiola 2006) In the same train of thought
children of first generation immigrants also known as second-generation immigrants have been
found to have higher risk of developing a psychotic disorder than their parents (Veiling et al
2006 Cantor-Graae ampSelten 2005) Further analysis is needed to confirm the extent of the effect
of immigration has on the endorsement of APPS on top of discrimination in our sample
Socio-demographic variables such as income neighborhood onersquos living in and
traumatic life experiences are also important factors linked to psychosis (eg Von Os et al 2009
Boydell et al 2001 Beards et al 2013Fisher et al 2009) Beards et al (2013) found that adults
who were exposed to traumatic life events were several times more likely to develop psychotic
experiences than those who do not Anglin Polanco-Roman amp Lui (2015) found that
dissociation mediated the relation between traumatic life experiences and APPS But such
relation was dependent upon onersquos ethnicity Notably full mediation was only present in the
black subgroup partially present in Hispanics and not found in Asians In term of gender
difference Fisher et al (2009) found that severe physical or sexual abuse in childhood is linked
to later psychosis in women more than men Boydell et al (2007) found individuals living in
neighborhood where they were ethnically well-represented were at lower risk for psychosis than
those who live in neighborhoods where they were minorities Furthermore people of lower
socio-demographic who see societyrsquos continuously hinder their efforts to move up the socio-
economic ladder may fall into social defeat (Cantor-Graae Selton 2005) Selton amp Cantor-Graae
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 28
(2005) hypothesized that social defeat which they defined as a positon of submission or be an
outsider may be a link to schizophrenia As evidence they cited a series of animal experiments
which showed that constant exposure to social defeat leads to a hyperactivity of the dopamine
mesolimbic system In humans the dopamine mesolimbic system is oversensitive in
schizophrenic individuals Therefore they suggested that just like in animals socially defeated
humans may have sensitive mesolimbic dopamine system which may heighten their descent to
psychosis Further research could indicate the level of social defeat trauma and the type of
neighborhood associated to the black sample of our study and how they work with discrimination
to explain their high endorsement of APPS and APPS distress
Limitations
There are several limitations in our study The first of our limitations is our reliance to APPS
through the PQ scale Loewy et al (2005 2007) accentuated that the PQ is not a clinical
assessment tool Instead it should be taken as a tool that pinpoints those who may be found at
risk of psychosis when assess through clinically valid interviews The second of our limitations
is that endorsing APPS alone through the PQ scale is not indicative of risk of psychosis Peoplersquos
hunger fatigue concentration culture religion may all affect the way they respond to the
questionnaire For example people who are hungry and tired may not pay as much attention to
the questionnaire and falsely answer a series of items Alternatively their understanding of
hallucinations or other positive psychotic symptoms may be skewed through their cultural and
religious understanding People also could have other disorders which influence their responses
David et al (1999) showed that Latinos with PTSD were more likely to endorse psychotic
symptoms in self-report questionnaires The third of our limitations is the sample used All of our
participants are college based The results may lack the external validity needed to extend the
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 29
findings to the general population Lastly data was collected on a single point in time for each
participant making this study not as strong as a longitudinal study which could have shown the
progression of the symptoms in the participants
Reference List
Abel KM Drake R Goldstein JM (2010) Sex differences in schizophrenia International Review
of Psychiatry 22(5) 417-428 http doi 103109095402612010515205
AddingtonD AddingtonJ amp PattenS (1996) Gender and affect in schizophrenia Canadian
Journal of Psychiatry 41(5) 265ndash268
Albus M Scherer J Hueber S et al (1994) The impact of familial loading on gender
differences in age at onset of schizophrenia Acta Psychiatrica Scandinavica 89 (2) 132ndash134
Aleman A Kahn R S and Selten J P (2003) Sex differences in the risk of schizophrenia
evidence from meta-analysis Archives of General Psychiatry 60(6) 565ndash571
American Psychiatric Association [APA] (2013) Diagnostic and Statistical Manual of Mental
Disorders (Fifth ed) Arlington VA American Psychiatric Publishing
Anglin DM Polanco-Roman L Lui F (2015) Ethnic variation in whether dissociation
mediates the relation between traumatic life events and Attenuated Positive Psychotic
SymptomsJourmal of Trauma amp Dissociation 16 68-85
Anglin DM Lighty Q Greenspoon M Ellman LM (2014) Racial discrimination is
associated with distressing subthreshold positive psychotic symptoms among US urban ethnic
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 30
minority young adults Society Psychiatry and Psychiatric Epidemiology Retrieved from
httpdoi 101007s00127-014-0870-8
Austad G Joa I Johannessen J O Larsen T K (2013) Gender differences in suicidal
behavior in patients with first-episode psychosis Early Intervention in Psychiatry Retrieved
online httpdoi 101111eip12113
BarajasA OchoaS Jordi E O and Lalucat-Jo LL (2015) Gender Differences in Individuals
at High-Risk of Psychosis A Comprehensive Literature Review The Scientific World Journal
2015 1-13 Retrieved from httpdxdoiorg1011552015430735
Beards S Gayer-Anderson C Borges S Dewey M E Fisher H L amp Morgan C(2013)
Life events and psychosis A review and meta-analysisSchizophreniaBulletin39 740ndash747 doi
101093schbulsbt065
BhuiK Stansfeld S McKenzie K Karlsen S Nazroo J Weich S (2005) RacialEthnic
Discrmination and Common Mental Disorders among workers Findings from the EMPIRIC
study of Ethnic minority Groups in the United Kingdom Journal of Public Health 95(3) 496-
501
Bhugra D Hiwig M Hossein B Marceau H Neehall J Leff J et al (1996) First-contact
incidence rates of schizophrenia in Trinidad and one-year follow-up British Journal of
Psychiatry 169 587-592
Bhugra D Leff J Mallett R Der G Corridan B Rudge S (1997) Incidence and outcome
of schizophrenia in whites African-Caribbean and Asians in London Psychological Medicine
27 791-798
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 31
BhugraD HilwigM Mallett R Corridan B Leff J Neehall J amp Rudge S (2000)
Factors in the onset of schizophrenia a comparison between London and Trinidad samplesActa
Psychiatria Scandinavica 101 135-141
Boydell J Van Os J McKenzie K Allardyce J Goel R McCreadie RG et al (2001)
Incidence of schizophrenia in ethnic minorities in London ecological study into interactions with
environment British Medical Journal 323 1336-1338
Breshnahan M Begg M D Brown A Shafter C Sohler N Insel B et al (2007) Race
and risk of schizophrenia in a US birth cohort another example of health disparity
International journal of Epidemiology 36 751-758
Brown T N Williams D R Jackson J S Neighbors H W Torres M Sellers S L
Brown K T (2000) ldquoBeing Black and Feeling Bluerdquo The mental health consequences of racial
discrimination Race amp Society 2(2) 117-131
Carter R T (2007) Racism and Psychological and Emotional Injury Recognizing and
Assessing Race-Based Traumatic StressThe Counseling Psychologist 35(13) 13-105 httpdoi
1011770011000006292033
Cantor-Graae ESelten JP (2005) Schizophrenia and migration a meta-analysis and review
American journal of Psychiatry 162 12-24
CottonS M Lambert M Schimmelmann B G et al (2009) Gender differences in premorbid
entry treatment and outcome characteristics in a treated epidemiological sample of 661 patients
with first episode psychosis Schizophrenia Research 114 (1ndash3) 17ndash24
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 32
DeNavas-Walt C Proctor B D and Smith JC (2011) Income Poverty and Health Insurance
Coverage in the United States 2010 In US Census Bureau Current Population Reports (pp
60-239) Washington DC US Government Printing Office Retrieved from
httpwwwcensusgovprod2011pubsp60-239pdf
Fearon P kirkbrideJ MorganC DazzanPMorgan K LLoyd T et al(2006) Incidence of
schizophrenia and other psychoses in ethnic minority groups results from the MRC AESOP
Study Psychological Medicine pp 1541-1550 doi101017S0033291706008774
Fisher HMorganC DazzanP Craig T K MorganK Hutchinson G et al (2009) Gender
differences in the association between childhood abuse and psychosis The British Journal of
Psychiatry 194 (4) 319-325 httpdoi 101192bjpbp107047985
Foti D J Kotov R Guey L T and Bromet E J (2010) Cannabis use and the course of
schizophrenia 10-year follow-up after first hospitalization American Journal of Psychiatry
167(8) 987ndash993
GalderisiSBucci P UccedilokA PeuskensJ (2012) No gender differences in social outcome in
patients suffering from schizophrenia European Psychiatry 27 406-408 Retrieved from
httpdoi101016jeurpsy201101011
Goldstein J M Tsuang M T Faraone S V (1989) Gender and schizophrenia implications
for understanding the heterogeneity of the illness Psychiatry Research 28(3) 243ndash253
Gottesman II McGuffin P amp Farmer AE (1987) Clinical genetics as clues to the ldquorealrdquo
genetics of schizophrenia a decade of modest gains while playing for time Schizophrenia
Bulletin 13 23-47
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 33
GurejeO(1991) Gender and schizophrenia age at onset and sociodemographic attributes Acta
Psychiatrica Scandinavica 83(5) 402ndash405
Hayashi N Igarashi Y Yamashina M Suda K (2002) Is there a gender difference in a
factorial structure of the positive and negative syndrome scale A test by structural equation
modeling Psychopathology 35 (1) 28ndash35
Hickling FW amp Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in
Jamaica British Journal of Psychiatry 167 193-196
Johns LC amp Van OS J (2001) The continuity of psychotic experiences in the general
population Clinical Psychology Review 21 1125-1141
Krieger N amp Sidney S (1996) Racial Discrimination and blood pressure The CARDIA study
of young black and white adults American Journal of Public Health 86 1370-1378
Doi102105AJPH86101370
Krieger N Smith K Naishadham D Hartman C Barbeau E M (2005) Experiences of
discrimination validity and reliability of a self-report measure for population health research on
racism and health Soc Med 61(7) 1576-1596
Lambert SF English D Ialongo NS (2014) Longitudinal Associations between Experienced
Racial Discrimination and Depressive Symptoms in African Americans Adolescents
Developmental Psychology 50(4) 1190-1196
Leung A Chue P (2000) Sex differences in schizophrenia a review of the literature Acta
Psychiatry Scandinavica Supplementum 4013-38
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 34
Lindstrom E amp Von Knorring L (1994) Symptoms in schizophrenic syndromes in relation to
age sex duration of illness and number of previous hospitalizations Acta Psychiatrica
Scandinavica 89 (4) 274ndash278
Loewy RL Bearden CE Johnson JK Raine A Cannon TD (2005) The prodromal
questionnaire (PQ) Preliminary validation of a self-report screening measure for prodromal and
psychotic syndromes Schizophrenia Research 79 117-125
Loewy RL Bearden CE Cannon TD (2007) Self-report of Attenuated Psychotic
experiences in a college Population Schizophrenia Research 93 (1-3) 144-151
Mahy GE Mallett R Leff Jamp Bhugra D (1999) First-contact incidence rate of
schizophrenia on Barbados British Journal of Psychiatry 175 28-33
Mangalore R1 Knapp M (2007) Cost of schizophrenia in EnglandJournal of Mental Health
policy and economic10(1) 23-41
McGlashan TH Miller TJ Woods SW Hoffman RE and Davidson L (2001) A scale
for the assessment of prodromal symptoms and states In Miller TJ Mednick SA
McGlashan TH Liberger J and Johannessen JO (Eds) Early Intervention in Psychotic
Disorders Dordrecht The Netherlands Kluwer Academic Publishers pp 135-149
McGlashan T H Walsh B C Woods S W (2010) Structured Interview for Psychosis-Risk
Syndromes (5th version) Prime Research Clinic Connecticut In print
McGrath J Saha S Chant D and Welham J (2008) Schizophrenia a concise overview of
incidence prevalence and mortality Epidemiologic Reviews 30(1) 67ndash76
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 35
Miller T I McGlashan T H Rosen J L Cadenhead K Ventura J Farlane W hellip Woods
S W (2003) Prodromal Assessment with the Structured Interview for Prodromal Syndromes and
the Scale of Prodromal Symptoms Predictive validity Interrater validity and Training to
Reliability Schizophrenia Bulletin 29 (4) 703-715
Miller TJ McGlashan TH Woods SW Stein K Driesen N Corcoran CM Hoffman
R and Davidson L (1999) Symptom assessment in schizophrenic prodromal states Psychiatric
Quarterly 70 273-287
Morgan V A Castle D J and Jablensky A V (2008) Do women express and experience
psychosis differently from men Epidemiological evidence from the Australian National Study
of Low Prevalence (Psychotic) Disorders Australian and New Zealand Journal of Psychiatry 42
(1) 74ndash82
Ochoa S Usall J Cobo J Labad X Kulkarni J (2012) Gender differences in
schizophrenia and First-Episode Psychosis A Comprehensive Literature Review Schizophrenia
Research and treatment 2012 Retrieved from httpdxdoiorg1011552012916198
OchoaS UsallJ Villalta-Gil V et al (2006) Influence of age at onset on social functioning in
outpatients with schizophrenia European Journal of Psychiatry 20(3) 157ndash163
Pascoe EA Richman LS (2009) Perceived discrimination and health a meta-analytic review
Psychology bulletin 135(4) 531-554 httpdoi101037A0016059
Peraumllauml J SuvisaariJ Saarni S I et al (2007) Lifetime prevalence of psychotic and bipolar I
disorders in a general population Archives of General Psychiatry 64(1) 19ndash28
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 36
Phanthunane P Whiteford H Vos T Bertram M (2012) Economic burden of schizophrenia
empirical analyses from a survey in ThailandJournal of Mental Health policy and
economic15(1) 25-32
Rodriacuteguez-Jimeacutenez R Araguumleacutes M Jimeacutenez-Arriero M A et al (2008) Dual diagnosis in
psychiatric inpatients prevalence and general characteristics Investigacion Clinica 49 (2)195ndash
205
Rosen JL Woods SW Miller TJ and McGlashan TH (2002) Prospective observations of
emerging psychosis Journal of Nervous and Mental Disorders 190133-141
Saha S Chant D Welham J McGrath J (2005) A systematic review of the prevalence of
schizophrenia PLoS Med 2(5) doi 101371journalpmed0020141
Sartorius N Shapiro R amp Jablonsky A (1974) The international pilot study of
schizophrenia Schizophrenia Bulletin 2 21-35
Shorter-Gooden K Washington NC (1996) Young Black and female The challenge of
weaving an identityJournal of Adolescence 19 465-475
Shorter-Gooden K Jones C (2003) Shifting The double Lives of Black Women in America
New York NY HarperCollins Publishers
Shtasel D L Gur R E Gallacher F Heimberg C and Gur R C (1992) Gender differences
in the clinical expression of schizophrenia Schizophrenia Research 7(3) 225ndash231
Silvia C (2010) The Gender Paradox in Suicide Suicide and Life Threatening Behavior 28
(1) 5 doi101111j1943-278X1998tb00622x
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 37
Sims A (2002) Symptoms in the mind an introduction to descriptive psychopathology
Philadelphia W B Saunders
Singh T amp Rajput M (2006) Misdiagnosis of Bipolar Disorder Psychiatry (Edgmont) 3(10)
57ndash63
Sproston K Nazroo JY (2002) Ethnic Minority Psychiatric Illness Rates in the Community
(EMPIRIC)London England The Stationery Office
Uggerby P Nielsen R E Correll C U Nielsen J (2011) Characteristics and predictors of
long-term institutionalization in patients with schizophrenia Schizophrenia Research 131(1ndash3)
120ndash126
Usall J Ochoa S Araya S Maacuterquez M (2003) Gender differences and outcome in
schizophrenia a 2-year follow-up study in a large community sample European Psychiatry
18( 6) 282ndash284
Van Os J Linscott R J Myin-Germeys I DelespaulP and Krabbendam L (2009) A
systematic review and meta-analysis of the psychosis continuum evidence for a psychosis
pronenessndashpersistencendashimpairment model of psychotic disorder Psychological Medicine 39
179-195 doi101017S0033291708003814
Veilin W Selten JP Veen N Laan W Blom JD amp Hoen HW (2006) Incidence of
schizophrenia among ethnic minorities in the Netherlands a four-year first-contact
studySchizophrenia Research 86 189-193
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 38
Veling W Selten JP Susser E Laan W Mackenbach JP Hoek HW (2007) Discrimination
and the incidence of psychotic disorders among ethnic minorities in The Netherlands
International Journal of Epidemiology 36(4) 761-768 doi 101093ijedym085
Veling W Susser E van Os J Mackenbach JP Selten JP Hoek HW (2008) Ethnic density of
neighborhoods and incidence of psychotic disorders among immigrants Am J psychiatry 165
66-73
Williams DR amp Mohammed S A (2009) Discrimination and racial disparities in health
Evidence and needed researchJournal of Behavioral Medecine 32 20-47
Doi101007s10865-008-9185-0
Wu EQ1 Birnbaum HG Shi L Ball DE Kessler RC Moulis M Aggarwal J (2005) The
economic burden of schizophrenia in the United States in 2002 Journal of Clinical Psychiatry
66(9) 1122-1129
Yung AR Phillips LJ Yuen HP Francey SM McFarlane CA Hallgren M McGorry PD
(2003) Psychosis prediction 12 month follow up of a high risk (ldquoprodromalrdquo) group
Schizophrenia research60 (1) 21-32
Yung A R McGorry P D McFarlane C A et al (1996) Monitoring and care of young
people at incipient risk of psychosis Schizophrenia Bulletin 22 283ndash 303
Yung A Phillips L J McGorry P D et al (1998) A step towards indicated prevention of
schizophrenia British Journal of Psychiatry 172 (33) 14ndash20
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 39
Table 1- descriptive information of the sample on gender race and endorsement of APPS
and discrimination
Overall Sample (n =
1633)Black ( n=512) White (n=1121)
Demographics
Female n () 1189 (729) 387 (756) 802 (715)
Age (years) mean (SD) [range] 2021 (204) [18-29]
205 (24) [18-29]
2007 (183) [18-29]
Race n ()
Black 512 (314) --- ----
White 1121 (686) --- ----
Immigrant Status n ()
US Born 1426 (873) 386 (758) 1040 (928)
US foreign 204 (125) 123 (242) 81 (72)
APPS mean (SD) [range]41 (566)[0-40] 675(73) [0-31] 289 (396) [0-
40]
APPS-distress mean (SD) [range] 172 (308) [0-23] 248 (382)[0-23] 135 (254)[0-19]
Frequency of Discrimination mean (SD) [range]
226(319) [0-25] 404(416)[0-23] 092 (168)[0-14]
Domain of Discrimination mean (SD) [range]
119 (150) [0-9] 21 (188)[0-9] 048 (08)[0-5]
APPS = Attenuated Positive Psychotic Symptoms
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 40
Table 2- Unadjusted regression lines of EODfreq gender to APPS for the black
subsample
APPS b(se)[p-value]
Step 1 Step 2
Gender 239 (075) [p=0001] 219 (075)[p=0003]
EODfreq 0215 (0077) [p=0005]
Constant 618 (0368)[plt0001] 536 (0469) [plt0001]
Unadjusted R2 020 [p=0001] 035[p=0005]
Figure1- APPS means by Racegender
Black male Black female white female white male0
1
2
3
4
5
6
7
8
9
857
618
386476M
ean
endo
rsem
ent o
f APP
S
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 41
Figure2- high vs low endorsement of APPS-distress by racegender
black male black female white man white female0
20
40
60
80
100
120
18 11127
48
82 889972 952
Highlow
combination of racegender
hi
gh v
s low
end
oers
emtn
of A
PPS-
dist
ress
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 42
Figure 3- Mean frequency of discrimination by racegender combination
black male black female white male white female0
05
1
15
2
25
3
35
4
45
5
474
382
091 093
frequency of discrimination
combination of race and gender
mea
n fr
equn
cy o
f disc
rimin
ation
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
Discrimination Race Gender amp APPS 43
Figure 4- Mean of endorsed domain of discrimination by racegender combination
Black male Black female White female White male0
05
1
15
2
25
234203
0478 0486
Mean domain of discrimination endorsed
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