Impact of Race, Ethnicity, and Culture on the Expression and Assessment of Psychopathology

Chapter 4
Impact of Race, Ethnicity, and Culture on the Expression and Assessment of Psychopathology


L. Kevin Chapman, Ryan C. T. DeLapp, and Monnica T. Williams


This chapter provides an overview and framework for understanding race, ethnicity, and culture as factors that affect adult psychopathology. Of primary interest are the assessment and treatment of psychopathology that integrates culturally salient values, ideologies, and behaviors into the mental health care of ethnic minorities. Moreover, the chapter is organized into two sections. In the first section, we present a model that highlights relevant multicultural factors that should be considered when working with ethnic minorities. The second section provides a discussion of how to effectively apply the knowledge of these multicultural factors when assessing or treating individuals with diverse ethnic backgrounds. Ultimately, the main objective of this chapter is to encourage mental health professionals to acknowledge the impact of race, ethnicity, and culture on adult psychopathology in order to optimize the efficaciousness of mental health services provided to ethnic minority individuals.


Existing literature has clearly demonstrated the importance of multicultural competency in the assessment and treatment of ethnic minorities. Particularly, the relevance of ethnicity (or “a voluntaristic self-identification with a group culture, identified in terms of language, religion, marriage patterns and real or imaginary origins”; Bradby, 2012, p. 955) in adult psychopathology has been substantiated by evidence identifying disparities in prevalence rates, symptom presentation, and severity, as well as mental health service utilization across diverse ethnic groups. For example, Himle et al. (2009) found that most anxiety disorders (with the exception of PTSD) were more prevalent among non-Hispanic Whites in comparison to African Americans and Caribbean Blacks. However, despite their lower prevalence rates, researchers reported that African Americans and Caribbean Blacks experienced anxiety disorders that were greater in severity and more functionally impairing, which demonstrates how experiences with mental illness can vary by ethnicity. Moreover, ethnicity has been implicated as a differentiating factor in the diagnosis and treatment of schizophrenia (Fabrega et al., 1994; Gara et al., 2012).


These studies highlight the susceptibility of misdiagnosed schizophrenia in African American patients due to the tendency for African Americans to endorse more psychotic symptoms during diagnostic assessments. As a result, Gara and colleagues (2012) emphasize the importance of culturally sensitive diagnostic assessment tools by explaining how an inability to effectively discriminate schizophrenia and schizoaffective disorders can lead to poor treatment outcomes. Additionally, the relevance of ethnicity in adult psychopathology is bolstered by the findings of Alegría and colleagues (2007), who used data from the National Latino and Asian Study (NLAAS) to identify factors that influence the treatment seeking behaviors of Latino individuals. Specifically, researchers found that the age of migration, Latino ethnicity (e.g., Mexican, Puerto Rican), birth origin (e.g., U.S.-born, foreign-born), primary language spoken, and years of residency in the United States were all influential factors in the use of mental health services and the satisfaction with care received. Most notably, these findings highlight the impact of varied immigration statuses on the perspectives that ethnic minority individuals bring to the mental health arena. Overall, the aforementioned studies clearly underscore the need for multicultural competency in mental health professionals given that one’s self-identification with an ethnic heritage has proven to be a vital differentiating factor in the presentation of symptoms and treatment outcomes across diverse adult samples.


Relevance of Ethnic Identity and Acculturation in Adult Psychopathology


An understanding of the interaction between multicultural factors (e.g., ethnic identity, acculturation) and sociocultural factors (e.g., socioeconomic status, life stress) in ethnic minority patients has become undeniably germane to providing these individuals with effective mental health care. Prior to learning “how” to integrate the understanding of this interaction within assessment, diagnostic, and treatment practices, mental health professionals must possess the knowledge of “what” multicultural factors exist. Accordingly, Carter, Sbrocco, and Carter (1996) have proposed a theoretical model that acknowledges the role of ethnicity, or a “shared culture and lifestyle,” as a pivotal underlying construct in the epidemiology, symptom expression, and treatment of psychopathology in ethnic minority individuals (p. 456). Though initially created to explain variations of anxiety disorders in African Americans, the Carter et al. (1996) model can be utilized to more broadly understand the relationship between ethnicity and adult psychopathology by comprehending the salience of ethnic identity and acculturation in all ethnic minorities.


In particular, ethnic identity is a multifarious construct characterized by how people develop and maintain a sense of belonging to their ethnic heritage (Roberts et al., 1999). Important factors influencing a person’s ethnic identity include whether they personally identify as a member of an ethnic group, their sentiments and evaluations of the ethnic group, their self-perception of their group membership, their knowledge and commitment to the group, and their ethnic-related behaviors and practices (Burnett-Zeigler, Bohnert, & Ilgen, 2013). Extant literature has provided several models explaining the developmental stages of ethnic identity (Cross, 1978; Cross & Vandiver, 2001; Phinney, 1989). Collectively, each model describes identity shifts between ethnic ambivalence (lack of interest or pride in one’s ethnic background), ethnic exploration (curiosity in one’s ethnic background potentially accompanied by a devaluing of other ethnic heritages), and multicultural acceptance (integration of one’s commitment to their ethnic background and an appreciation for other ethnic heritages). Evidence supports that individuals high in ethnic identity (i.e., closer to multicultural acceptance) typically have higher levels of self-esteem, develop more protective coping mechanisms, experience more optimism, and report fewer psychological symptoms (Roberts et al., 1999; Smith, Walker, Fields, Brookins, & Seay, 1999; McMahon & Watts, 2002). Notably, Williams, Chapman, Wong, and Turkheimer (2012) compared the relationship between ethnic identity and the psychological symptoms of African American and European American adult samples. Researchers found that higher levels of ethnic identity were related to lower depressive and anxious symptoms in African Americans yet associated with a slight elevation in anxious symptoms for European Americans. Such findings illustrate the protective nature of a strong ethnic identity for minority members. However, some studies suggest that individuals with a strong sense of belonging to their native heritage can amplify the impact of culturally specific stressors (e.g., discrimination; social inequalities), thereby enhancing their focus on their difference from majority culture (Yip, Gee, & Takeuchi, 2008). Past literature has found that the stage of ethnic identity development, age, and level of perceived stress can attenuate the buffering influence of high ethnic identity (see review by Burnett-Zeigler et al., 2013).


Another relevant construct implicated in the Carter et al. (1996) model is acculturation, traditionally defined as the extent to which ethnic minorities adopt the values and participate in the traditional activities of mainstream culture. Recent reconceptualizations of the acculturation process utilize a multidimensional perspective where ethnic minorities must reconcile discrepancies in one’s identities (the salience of one’s ethnic versus national identity), one’s value system (individualism versus collectivism), one’s language proficiency, one’s cultural attitudes and knowledge, as well as one’s cultural practices (Park & Rubin, 2012; Schwartz et al., 2013; Yoon et al., 2013).


According to a meta-analysis of 325 studies about the relationship between acculturation and mental health, Yoon and colleagues (2013) found that mainstream language proficiency was negatively associated with negative mental health, whereas endorsing an ethnic identity was positively related to positive mental health. Most importantly, these findings demonstrate how complex the relationship between acculturation and psychopathology can be, which emphasizes the need for mental health professionals to consider the relevance of each acculturation dimension (e.g., identity, language, value system, behaviors) when working with ethnic minorities. Furthermore, the acculturative stress of integrating disparities in ethnic and mainstream culture across these dimensions can result in difficulties adapting to mainstream culture and/or perceived rejection from one’s native heritage (Schwartz et al., 2013), which has been associated with psychopathology in ethnic minority adults (e.g., more eating-disorder symptoms [Van Diest, Tartakovsky, Stachon, Pettit, & Perez, 2013]; greater levels of depression [Driscoll & Torres, 2013; Park & Rubin, 2012]). When confronted with such cultural disparities, extant literature has identified biculturalism, or the ability for ethnic minorities to effectively integrate elements of two cultural streams, as one of the most protective acculturation statuses against negative health outcomes (Schwartz et al., 2013).


Alternative acculturative statuses include strongly adhering to the mainstream culture and devaluing native heritage (assimilation), strongly adhering to the native heritage and devaluing the mainstream culture (separation), and exhibiting little interest in adhering to either cultural stream (marginalization; see Matsunaga, Hecht, Elek, & Ndiaye, 2010; Yoon et al., 2013). Overall, existing literature has yielded inconclusive findings clarifying the impact of acculturation on the mental health of ethnic minorities (see Concepcion, Kohatsu, & Yeh, 2013), which has been accredited to the multiple definitions of acculturation (e.g., time since immigration, language fluency, acculturation status) and examining this construct in few ethnic minority groups (Burnett-Zeigler et al., 2013; Yoon et al., 2013).


Aside from having knowledge of ethnic identity and acculturation, mental health professionals must also understand how these constructs interact to influence the psychopathology expressed in many ethnic minority individuals (Yoon et al., 2013). In referencing the Carter et al. (1996) model, African Americans who maintain a strong ethnic identity and are highly assimilated in the dominant culture are believed to endorse traditional beliefs of mainstream society (e.g., individualism) and exhibit symptoms presentations consistent with the current diagnostic nomenclature. Notably, it is theorized that these individuals may feel conflicted by being acculturated to believe psychological treatment is effective while embodying a mistrust of societal systems in mainstream culture as a result of historically significant cultural experiences (e.g., perceived discrimination from individuals of the dominant culture). Similarly, Carter et al. (1996) conceptualized that African Americans low in ethnic identity yet highly assimilated will exhibit a traditional symptom presentation, but be more willing to seek, persist through, and benefit from traditional treatment practices. In contrast, individuals high in ethnic identity who strongly de-identify with mainstream culture (separation acculturation status) represent a subset of ethnic minorities who may display unique symptom presentations and utilize culturally specific explanations for their symptoms, thereby resulting in a greater likelihood for misdiagnosed psychopathology. Further, these individuals are theorized to be less likely to seek treatment due to mistrust in and/or a limited knowledge of mental health care.


Although there is a dearth of literature devoted to examining the additive impact of ethnic identity and acculturation on adult psychopathology (Chae & Foley, 2010), several studies provide evidence supporting the broad application of the Carter et al. (1996) model across diverse ethnic minority groups. Burnett-Zeigler et al. (2013) examined the relationship between ethnic identity, acculturation, and the lifetime prevalence of mental illness and substance use in African American, Latino, and Asian samples. Results indicated that higher levels of ethnic identity, and not higher acculturation, were related to decreased lifetime prevalence of psychiatric illness and substance use for each minority group. Notably, higher acculturation (e.g., use of English language or social preference for individuals not in ethnic group) was associated with increased prevalence of depression in African Americans and Hispanics, increased bipolar diagnoses in Hispanics, and increased anxiety disorder diagnoses for all minority groups. Regarding substance use, higher acculturation was related to increased lifetime prevalence of alcohol and drug use among the Hispanic and Asian sample. These findings suggest that having a strong sense of pride and belonging to an ethnic heritage is protective; however, nondominant individuals who are unable to maintain cultural ties with their native heritage (e.g., first language, relationships with members of ethnic group) may be more susceptible to negative health outcomes.


Nascent literature has provided a more specific understanding of the interaction between these two constructs by utilizing acculturation statuses (e.g., integration, assimilation, separation) instead of a broad definition of acculturation (e.g., English literacy; time of residency). In particular, Matsunga and colleagues examined the interaction between ethnic identity and acculturation status in Mexican-heritage adolescents living in the southwest region of the United States and found that an integration acculturation status was more prevalent than assimilation as well as more predictive of a strong ethnic identification (Matsunaga et al., 2010), which suggests that a strong ethnic identity and a successful integration of two cultures are closely associated. Furthermore, Chae and Foley (2010) found that high ethnic identity strongly predicted positive psychological well-being among Chinese, Japanese, and Korean Americans whereas an assimilation acculturation status predicted poorer psychological well-being among Korean Americans. Also, researchers found that Asian Americans with an integration acculturation status experienced significantly higher psychological well-being compared to other acculturation statuses. Most importantly, these findings suggest that ethnic minorities who maintain a strong sense of belonging to their ethnic heritage (high ethnic identity) and who have successfully integrated the identities, value systems, and cultural practices of their native and mainstream heritages (integration) exhibit fewer clinical symptoms and more life satisfaction.


Relevance of Sociocultural factors in Adult Psychopathology


Though an understanding of the aforementioned constructs is essential, it is equally important to examine the impact of other sociocultural variables that also exert a considerable degree of influence over the symptom presentation and treatment outcomes of ethnic minorities. Although extant literature has identified a myriad of variables that impact minority mental health, the current chapter solely focuses on socioeconomic status (SES), stressful life events, and age cohort, which were each identified by the Carter et al. (1996) model as important contributors to the mental health of ethnic minorities.


Researchers propose that SES can provide a more precise understanding of the relationship between ethnicity and adult psychopathology by focusing on the specific environmental elements that characterize each social class. Past literature has shown that high SES is related to better health outcomes. One study by Shen and Takeuchi (2001) examining the relationship between acculturation, SES, and depression in Chinese Americans found that SES was a better indicator of depressive symptoms than acculturation and that high SES individuals (i.e., high educational attainment and increased income) were related to better mental health outcome (i.e., fewer depressive symptoms) compared to low SES individuals. These findings suggest that it is through the variance in SES and related variables (e.g., perceptions of stress, social support, and physical health) that acculturation may impact the mental health of nondominant individuals (Shen & Takeuchi, 2001). Contrarily, nascent literature has begun to propose that the association between social class and mental health is much more complex in that evidence has supported that low SES and/or foreign-born individuals are not automatically guaranteed poor health outcomes (John, de Castro, Martin, Duran, & Takeuchi, 2012). Given such findings, it suggests that mental health professionals should acknowledge the detrimental as well as the protective elements of one’s social class.


Also, the Carter et al. (1996) model identifies stressful life events as a contributor to the variability in the psychopathology of ethnic minorities. Though a comprehensive understanding of the multiple forms of stress (e.g., violence exposures, neighborhood context, poverty, etc.) is beyond the scope of this chapter, extant literature pinpoints race/ethnic-based stress as influential to the mental health of ethnic minority individuals. In particular, Greer (2011) describes racism as “complex systems of privilege and power, which ultimately serve to threaten and/or exclude racial and ethnic minorities from access to societal resources and other civil liberties” (p. 215). As a result of such racial/ethnic injustice, many ethnic minorities are subjected to damaging race/ethnic-focused attitudinal appraisals (i.e., prejudice), race/ethnic-focused assumptions (i.e., stereotypes), and unjust treatment based upon their race/ethnicity (Greer, 2011).


Past studies have indicated that exposure to such race/ethnic-based experiences are strong indicators of mental health outcomes across diverse ethnic minority groups (e.g., discrimination was related to increased lifetime prevalence of generalized anxiety disorder in African Americans [Soto, Dawson-Andoh, & BeLue, 2011]; perceived discrimination was associated with increased anxiety, affective, substance abuse disorders among African Americans, Hispanic Americans, and Asian Americans [Chou, Asnaani, & Hofmann, 2012]). Notably, empirical evidence suggests that perceived discrimination may be particularly salient to African American clients, given that several studies have found African Americans to endorse greater degrees of perceived discrimination in comparison to other ethnic minority groups in the United States (Cokley, Hall-Clark, & Hicks, 2011; Donovan, Huynh, Park, Kim, Lee, & Robertson, 2013). Overall, when utilizing ethnic identity and acculturation to gain insight into the culturally specific worldviews of nondominant individuals, it is imperative that mental health professionals also examine the occurrence and impact of race/ethnic-based stressors on the psychopathology of ethnic minorities.


Finally, the Carter et al. (1996) model discusses the relevance of age cohort in the manifestation of psychopathology in ethnic minorities. The evolution of the “social, economic, and political climate” in the United States has yielded diverse experiences across generations of ethnic minorities in this country, thereby impacting the meaning of ethnicity for each generation (Carter et al., 1996, p. 460). In the context of each ethnic group, there are different historical details separating each generation; however, the impact of age cohort on psychopathology remains a relevant consideration. In general, existing literature has implicated intergenerational disparities in perceived racial discrimination (Yip et al., 2008), ethnic identity (Yip et al., 2008), acculturation status (Buscemi, Williams, Tappen, & Blais, 2012), and lifetime prevalence of psychiatric illness (Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006) across the adult lifespan. One study particularly relevant to this chapter’s discussion of the Carter et al. (1996) model examined the protective and/or exacerbating nature of ethnic identity in the relationship between racial discrimination and psychological distress in Asian adults (Yip et al., 2008). Results indicated that ethnic identity appeared to buffer the negative impact of racial discrimination on the psychological distress for adults ages 41 to 50 yet exacerbate the effects of racial discrimination for adults ages 31 to 40 and 51 and older. In an attempt to explain these findings, Yip and colleagues (2008) theorize that the former age cohort is more likely to have a stable lifestyle with more coping mechanisms for stress, whereas the latter age cohorts may characterize adults who are in the exploration phase of their ethnic identity, which, therefore, heightens their sensitivity to being unfairly treated on the basis of their race/ethnicity. Furthermore, the parent-child relationship is another important way that intergenerational differences can impact adult psychopathology, especially for immigrant families (Kim, 2011; Vu & Rook, 2012).


In a study examining intergenerational acculturation conflict and depressive symptoms among Korean American parents, Kim (2011) found that greater discrepancies in cultural values between parent and child (greater intergenerational conflict) was related to increased parental depressive symptoms; an association more pronounced in mothers compared to fathers. It was proposed that the cultural expectations of the Korean mother (e.g., to be a “wise and benevolent” primary care giver) was conflicted by an incongruence with the value system of mainstream culture (Kim, 2011, p. 691). Collectively, such findings provide evidence that the Carter et al. (1996) model elucidates culturally specific considerations for psychological distress among diverse ethnic minorities.


Section 2: Application of Multicultural Factors


Prior to addressing how the aforementioned factors can be applied to enhance the efficiency and effectiveness of treatment in ethnic minority patients, it is equally important to understand how culture, race, and ethnicity impact the evaluation of psychopathology within such populations. In the following section, the pertinence of validating assessment tools among ethnic minority groups is discussed. In particular, there is a general overview of common statistical methods used to establish measurement equivalence across diverse groups as well as important considerations when translating the results of such statistical methods to the in vivo assessment of ethnic minority clients.


Assessment


Historically, there has been a ubiquitous disconnect between investigating various facets of theoretical models that are endemic to ethnic minority populations, and the subsequent application of these constructs in practice. As mentioned earlier, there are a number of unique, culturally specific factors that undoubtedly influence the manifestation (and subsequent treatment) of various forms of psychopathology. There is a substantive literature underscoring the exigency for conducting translational research in ethnic minority populations that are beyond the scope of this chapter (for a review, see Hofmann & Parron, 1996; Nagayama Hall, 2001). Worth noting, however, are two relatively salient implications from the empirical literature. First, the need for culturally sensitive assessment tools that aid in the diagnosis of psychopathology in ethnic minority individuals. Second, the need for investigators to delineate ingredients for culturally sensitive interventions, presumably as a result of uncovering culturally specific factors through rigorous assessment in ethnic-minority populations.


As noted in the previous edition of this chapter, establishing measurement equivalence (or lack thereof) is paramount before proceeding with effective translational research, particularly as it relates to ethnic minority populations. In the previous edition, the authors described (a) linguistic/translation equivalence (accuracy of translation/understanding from the perspective of the ethnic minority individual), (b) conceptual equivalence (whether the underlying construct maintains the same meaning in ethnic minority individuals as in European Americans), and (c) psychometric equivalence (whether the construct is measured the same across groups). Given that the previous edition provided readers with a thorough overview of the various components of measurement equivalence, the scope of the current chapter is to highlight more recent work in the area of measurement equivalence with the aim of delineating potential “ingredients” for culturally sensitive assessment tools in ethnic minority populations. Only a brief summary is provided in this edition.


The most important prerequisite to assessment with ethnic minority populations is taking a multicultural perspective rather than an ethnocentric one. In short, multiculturalism refers to the recognition of equality of various cultural groups and the right of individuals to follow their own specified paths (Shiraev & Levy, 2013). Ethnocentrism, on the other hand, refers to a cognitive bias that supports “judgment about other ethnic, national and cultural groups from the observer’s perspective” (Shiraev & Levy, 2013, p. 19). Along these lines, when considering linguistic translation equivalence, one point worth noting is that evaluators must remain cognizant of the cognitive biases that we all possess and subsequently acknowledge that our literacy is culturally based (Shiraev & Levy, 2013).


Although many concepts translate naturally across cultures (e.g., numbers), scientists and practitioners need to be increasingly mindful of the interplay between culture, race, and ethnicity during all types of assessment. As previously noted, differences in racial identity, age, participation in acculturation experiences, and environment could significantly impact how many ethnic minority individuals respond to questions on a particular measure. Generally agreed upon standards have been established when language differences exist, particularly as it relates to forward and backward translation (e.g., Butcher, 1996). Appropriately trained, bilingual administrators are critically important when establishing linguistic translation equivalence.


More recently, significant strides have been made in the realm of conceptual and psychometric equivalence across racial and ethnic minority groups. Beyond basic theory, the question of conceptual equivalence can most accurately be investigated by determining psychometric equivalence. As such, it should be noted that the lack of either conceptual or psychometric equivalence neither precludes the elimination of an assessment tool nor suggests that the measure is not useful with a given ethnic minority population. Depending on the properties of the given measure, results of statistical analyses may suggest the necessity to modify the assessment tool into a more effective screener as a precursor for further diagnostic assessment (detailed later). Nonetheless, psychometric equivalence is arguably the most important standard to establish in order to fully understand how to proceed with assessment and subsequent treatment geared toward ethnic minority individuals.


Before proceeding, it is important to reemphasize the importance of heterogeneity in ethnic minority individuals and the relative differences in racial identity, acculturation, and the other previously described sociocultural constructs that influence the assessment experience. Historically, the exception during assessment has been to be mindful of cultural heterogeneity prior to assessment when, in fact, the understanding of this heterogeneity is most accurately described as the rule. Moreover, we are re-emphasizing the importance of assessing relevant sociocultural variables as a preamble to the discussion of a very promising area of investigation in ethnic minority assessment and treatment, specifically, factor pattern analyses with certain measures.


Factor Pattern Investigations in Ethnic Minorities


Perhaps the most promising investigations in this area are the nascent, factor analytic studies that examine factor patterns across racial and ethnic minority groups, particularly in the realm of anxiety and related disorders. The majority of these investigations have utilized structural equation modeling (SEM), a comprehensive yet flexible approach that allows the investigator to examine various relationships among variables while controlling for measurement error (see Bentler, 1990; Hu & Bentler, 1999). The ability of an investigator to control for measurement area when examining measurement equivalence while simultaneously examining various components of the general linear model makes this approach very attractive over traditional analytic methods.


Many investigators interested in the assessment and treatment of ethnic minority individuals have employed SEM in order to determine whether commonly used assessment tools are equivalent (or contain invariant factor patterns) across European American individuals (the majority in the United States) and ethnic minority individuals. The most commonly used method for making this determination is one facet of the SEM, confirmatory factor analysis (CFA) also referred to as the “measurement model” (Hoyle & Smith, 1994). In other words, does the construct that is purportedly measured by “X” tool in European Americans yield the same results in a specific ethnic minority population? Several studies have yielded promising results related to psychometric equivalence for various tools in the anxiety disorders literature for use with ethnic minority populations. For instance, Chapman, Petrie, and Vines (2012) found that the factor structure of the Symptom Checklist 90–Revised (SCL-90-R), a commonly utilized measure of psychological distress, was equivalent in a sample of African American females. These results suggest that the SCL-90-R in its current form has established empirical support for utilization in a community sample of African American females.


Other studies have examined measurement equivalence using similar methodology with disparate findings when utilizing different measures. As mentioned earlier, factor variance does not preclude the elimination of a measure; rather it may suggest the need for a modified version of the measure. For instance, Melka and colleagues (Melka, Lancaster, Adams, Howarth, & Rodriguez, 2010) examined the Fear of Negative Evaluation Scale (FNE) and the Social Avoidance and Distress Scale (SAD) in a sample of non-Hispanic White and African American young adults and found that several items on both measures needed to be omitted for the African American sample. Similarly, Chapman, Williams, Mast, and Woodruff-Borden (2009) investigated the original and other extant factor structures of the Beck Anxiety Inventory (BAI), arguably the most widely used self-report measure for anxiety symptoms in general, in a sample of African American and non-Hispanic White adults. Results revealed that the original factor structure was not equivalent in the African American sample and that a 19-item version of the BAI best fit the African American sample (Chapman et al., 2009). Similar results have been obtained with other, widely utilized measures of family functioning (Family Assessment Device; Chapman & Woodruff-Borden, 2009), specific phobias (Chapman, Kertz, Zurlage, & Woodruff-Borden, 2008; Chapman, Vines, & Petrie, 2011), and perceived control over anxiety (Chapman, Kertz, & Woodruff-Borden, 2009), further underscoring the importance of understanding cultural factors related to assessment in ethnic minority individuals.


Clinical Utility Assessment in Ethnic Minorities


In attempts to further understand which assessment tools have adequate clinical utility in ethnic minority samples, other investigators have employed statistical techniques aimed at predicting the presence of psychopathology from screening tools. The extent to which screening tools are sensitive at predicting the presence or absence of a specific disorder, particularly in ethnic minority populations, has a number of implications for clinical work. In short, the assessment process may be streamlined through early detection of disorders, which in turn allows the clinician to spend more time in (a) building rapport with ethnic minority clients and (b) engaging in time-limited, clinical intervention. Along these lines, a receiver operating characteristic analysis (ROC) is one such method that has been heavily utilized to predict the presence of various medical conditions (e.g., diagnosing breast cancer via digital mammograms [Cole et al., 2004]; pneumonia detection [Lynch, Platt, Gouin, Larson, & Patenaude, 2004]) and psychiatric conditions (e.g., dexamethosone suppression test for predicting major depressive disorder [Mossman & Somoza, 1989]; harm avoidance scores predicting generalized anxiety disorder [Rettew, Doyle, Kwan, Stanger, & Hudziak, 2006]; predicting PTSD with PTSD Checklist in female veterans [Lang, Laffaye, Satz, Dresselhaus, & Stein, 2003]).


Although a description of a ROC analysis is beyond the scope of this chapter, worth noting is that the ROC analysis calculates an area under the curve (AUC), which determines the suitability of a given measure as a screening tool, because it reflects the likelihood that a participant who meets criteria for a diagnosis selected at random will score higher on a measure than a randomly selected control participant (see Bredemeier et al., 2010). Moreover, a ROC analysis provides optimal cut scores for specific measures in predicting the presence of particular disorders. In a more recent investigation, Petrie, Chapman, and Vines (2013) investigated the sensitivity and specificity of the Positive and Negative Affect Scales Expanded Form (PANAS-X) at detecting social anxiety disorder in a sample of African American women. Results suggest that the PANAS-X is a clinically useful measure at predicting social anxiety disorder in African American females. More specifically, a score above 11 on the Negative Affect Scale of the PANAS-X indicates further examination (e.g., a diagnostic interview) is warranted to assess the presence of social-anxiety disorder, whereas a score below 35 on the Positive Affect Scale reveals the need for further examination to determine the presence of any anxiety disorder. Chapman, Petrie, and Richards (under review) yielded similar results with other measures predicting social anxiety disorder, specifically for the Social Phobia Scale (SPS; cut score of 6>), Albany Panic and Phobia Questionnaire (APPQ; score of 7>), Social Interaction Scale (SIAS; cut score of 15>), and a social “fear factor” from the Fear Survey Schedule–Second Edition (FSS-II; cut score of 7>). It should be noted that the social “fear factor” (see Chapman et al., 2008; Chapman et al., 2011) is composed of only four items.


Taken together, these results suggest that the assessment of sociocultural factors at the beginning of treatment in addition to the utilization of assessment measures that demonstrate clinical utility in ethnic minority samples (or when modification is necessary) is critically important to effective assessment. Readers are encouraged to further explore the aforementioned measures to further determine their clinical utility in ethnic minority samples.


Expression/Assessment of Psychopathology


Aside from the administration of culturally sensitive assessment tools to aid in the accurate diagnosis of psychopathology among ethnic minority patients, extant literature has implicated cultural factors endemic to ethnic groups that may influence the expression of their symptomology. In the following section, a general overview of how factors, such as perceived discrimination and stigma of mental illness, impact various forms of symptom expression among non-Western and Western ethnic groups is presented.


Expression of Psychopathology Differs Across Cultural Groups


It is often unclear how symptom profiles may differ between ethnic groups when typical research studies use structured instruments, based on an a priori set of questions believed to exemplify the disorder under investigation (Guarnaccia, 1997). Measures based on Western notions of prototypical symptoms will fail to capture cultural differences in the expression of all disorders. Thus, variations in symptom patterns are often overlooked or misunderstood. Such misunderstandings affect how we, in turn, conceptualize even seemingly well-defined disorders.


The DSM-5 recognizes several cultural concepts of distress, or mental disorders that are generally limited to specific cultural groups for certain dysfunctional and/or distressing behaviors, experiences, and observations (American Psychiatric Association, 2013). However, many culture-bound syndromes are likely unrecognized variations of common Western ailments. For example, susto is a Latin American folk illness attributed to having an extremely frightening experience, thought to include “soul loss” as part of the syndrome. People afflicted with susto may have symptoms that include nervousness, loss of appetite, insomnia, listlessness, despondency, involuntary muscle tics, and diarrhea. The symptoms of susto are actually quite similar to posttraumatic stress disorder (PTSD), which includes anxiety, avoidance, dissociation, jumpiness, sleep disturbances, and depression. When referring to soul loss within susto, a closer meaning to this may actually be loss of “vital force,“ as the soul is typically not thought to have actually left the body until death (Glazer, Baer, Weller, Garcia de Alba, & Liebowitz, 2004). This could resemble the fatigue and anhedonia, which may be a part of depressive symptoms within PTSD. Additionally, feeling as if one’s soul has been lost may be an idiom of distress for dissociation. Therefore, the concept of susto as a culture-bound syndrome may be better conceptualized as a culture-specific description of PTSD itself.


Interestingly, folk treatments for the disorder include elements of exposure-based therapies for PTSD (e.g., Williams, Cahill, & Foa, 2010). During the treatment ritual, the individual afflicted with susto must recount their terrifying experience while lying on the axis of a crucifix on the floor. Fresh herbs are swept over the afflicted individual’s body while the folk healer says a series of prayers (Gillette, 2013). Sugar, water, and tea may also be used (Glazer et al., 2004). If the first session is not effective, the process is repeated every third day until the patient is recovered. This repeated recounting process is a critical active ingredient in prolonged exposure, a highly effective treatment for PTSD developed by Foa, Hembree, and Rothbaum (2007), and likely accounts for the effectiveness of the folk remedy.


Another example of the connection between DSM disorders and culture-bound syndromes can be seen in the enigmatic ailment called koro. Though uncommon in Western cultures, koro is characterized by anxiety over the possibility of one’s genitalia receding into the body, resulting in infertility or death (Chowdhury, 1990). To prevent any envisioned shrinkage or retraction of the genitals, a koro sufferer will perform certain behaviors (i.e., pulling of genitals, spiritual rituals, securing genitals to prevent retraction) intended to reduce or eliminate this risk.


Obsessive-compulsive disorder (OCD) is characterized by distressing and typically implausible obsessions, with compulsions designed to reduce the anxiety caused by the obsessions. Davis, Steever, Terwilliger, & Williams (2012) note the possibility that koro is simply a form of OCD, as an alternative to the current classification as a culture-bound syndrome. The most salient feature of koro concerns the anxiety surrounding the retraction and shrinkage of genitalia. The degree to which this distress can impair the daily functioning of those with koro has marked similarities to the construct of obsessions in OCD. This, coupled with the improbability of one’s genitalia actually receding into one’s body, makes it possible to categorize this fear as an obsession.

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Jun 10, 2016 | Posted by in PSYCHOLOGY | Comments Off on Impact of Race, Ethnicity, and Culture on the Expression and Assessment of Psychopathology

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