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Journal of Psychopathology and Behavioral Assessment, Vol. 23, No. 2, 2001

Cultural Mistrust and the Clinical Diagnosis of Paranoid

Schizophrenia in African American Patients

Arthur L. Whaley

This study examined agreement between clinical diagnoses and research diagnoses of schizophrenia
for a sample of African American patients recently admitted to a psychiatric hospital. It also exam-
ined the association of cultural mistrust with disagreement between clinical diagnoses and research
diagnoses of the paranoid subtype of schizophrenia. Complete data was available for 118 (77%) of
the 154 cases from the original sample. Agreement among the different sources of diagnoses was
poor in 5 out of 6 comparisons. The lack of agreement can be attributed, in part, to the fact there
were significantly more cases of schizophrenia using clinical diagnoses than those using SCID or best
estimate methods. Contrary to the hypothesis, however, level of cultural mistrust did not predict the
excess in clinical diagnoses of paranoid schizophrenia. Cultural mistrust was positively associated
with the odds of a diagnosis of paranoid schizophrenia by the best estimate method. The implications
of the results for the diagnosis and treatment of African American patients are discussed.

KEY WORDS: African American; cultural mistrust; misdiagnosis; paranoia; schizophrenia.

The overdiagnosis of schizophrenia and the under-
diagnosis of affective disorder in African American pa-
tients using clinical diagnoses are consistent findings in
the psychiatric literature (Baskin, Bluestone, & Nelson,
1981; Snowden & Cheung, 1990). Clinical diagnoses for
the purposes of hospital admissions tend to be unstruc-
tured and thus are more susceptible to interpretive biases.
This pattern of diagnostic outcomes for Black psychi-
atric patients remains unchanged even with substantial
improvements in the DSM in the third and subsequent
editions (Neighbors et al., 1999; Strakowski et al., 1995,
1997; Trierweiler et al., 2000). Studies that examine the
overdiagnosis of schizophrenia at the subtype level in-
dicate that paranoid schizophrenia is the most frequent
clinical diagnosis given to African American patients
(Collins, Rickman, & Mathura, 1980; Mukherjee, Shukla,
Woodle, Rosen, & Olarte, 1983; Toch, Adams, & Greene,
1987). Moreover, Mukherjee et al. (1983) found that Black
bipolar patients were more likely to be misdiagnosed as
paranoid schizophrenic than their White and Hispanic
Department of Social Psychiatry, New York State Psychiatric Institute,
100 Haven Avenue, Tower 3-19E, New York, New York 10032; e-mail:
whaleya@pi.cpmc.columbia.edu.
counterparts, and the ethnic/racial difference was not at-
tributable to differences in symptom presentation.
Excess in clinical diagnoses of paranoid schizophre-
nia in African American patients that cannot be accounted
by symptom differences may be explained by cultural
factors. The overdiagnosis of paranoid schizophrenia in
Black psychiatric patients may result from clinicians’
lack of awareness of different cultural norms for para-
noid ideations in the Black population (Adebimpe, 1981,
1982; Baskin, 1984; Grier & Cobbs, 1968; Jones & Gray,
1986; Ridley, 1984). African Americans have developed
what some clinicians and researchers describe as “cultural
paranoia,” which is a normative, healthy, and adaptive re-
sponse to racism (Grier & Cobbs, 1968; Ridley, 1984;
Terrell & Terrell, 1981). This culturally based paranoia is
often referred to as “cultural mistrust” by researchers who
study the construct in order to distinguish it from clin-
ical symptoms (Terrell & Terrell, 1981, 1984; Whaley,
1998a, 1998b). Clinicians may treat cultural mistrust as a
symptom of clinical paranoia in their diagnostic decision
making, which increases the likelihood of false positive
diagnoses of paranoid schizophrenia.
The majority of studies on the mental health im-
plications of cultural mistrust have been conducted with

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94
college populations, and in a few cases with persons
seeking community mental health services (Whaley, in
press-a). These studies tend to show that Black individuals
high in cultural mistrust tend to have more negative atti-
tudes toward mental health services (Nickerson, Helms,
& Terrell, 1994), are more likely to terminate counsel-
ing or therapy prematurely or after one session, especially
with a White counselor (Terrell & Terrell, 1984), and dis-
close less to White counselors than to Black counselors
(Thompson, Worthington, & Atkinson, 1994). The low
self-disclosure has been the main focal point in the lit-
erature on misdiagnosis. Ridley (1984) asserted that the
misdiagnosis of schizophrenia in Black patients results
from the misinterpretation of “healthy cultural paranoia,”
manifested as low self-disclosure, as paranoid psychosis.
To date, there have been no studies of the role of cultural
mistrust in the clinical diagnosis of psychosis, particularly
paranoid schizophrenia.
This study examined agreement between clinical di-
agnoses and research diagnoses of schizophrenia for a
sample of African American patients recently admitted
to a psychiatric hospital. It also examined the association
of cultural mistrust with disagreement between clinical
diagnoses and research diagnoses of schizophrenia. Two
types of research diagnoses were used to address both
clinician bias or lack of adherence to diagnostic criteria
and cultural bias or insensitivity to true ethnic/racial dif-
ferences in symptom expression that may occur in clinical
diagnoses (Whaley, 1997). Previous research has shown
that race differences remain when controlling for lack of
adherence to diagnostic criteria by employing structured
clinical interviews (Pavkov, Lewis, & Lyons, 1989). The
residual race difference may represent underlying cultural
differences in symptom expression. Structured clinical in-
terviews are inadequate for detecting true cultural differ-
ences in the manifestation of psychiatric disorders (Lopez
& Nunez, 1987). The use of cultural experts may pro-
vide an approach that is sensitive to cultural differences
in the expression of psychopathology. The present study
employed a female African American psychiatrist and a
male African American psychologist, both with extensive
experience diagnosing severe mental illness in Black pa-
tients, as the cultural experts.
It was hypothesized that there will be more frequent
clinical diagnoses of schizophrenia, especially the para-
noid subtype, compared to those derived from Structured
Clinical Interviews for DSM IV (SCID; First, Spitzer,
Gibbon, & Williams, 1996) or best estimate diagnoses
by cultural experts. It was also hypothesized that excesses
in clinical diagnoses, defined as an intake or admission
diagnosis of schizophrenia and a research diagnosis of
a disorder other than schizophrenia, would be positively
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Whaley
correlated with level of cultural mistrust. Two sets of anal-
yses were conducted. The first set involved all subtypes
of schizophrenia combined. The second set of analyses
focused on paranoid schizophrenia to be consistent with
theoretical arguments regarding “cultural paranoia” and
diagnoses of schizophrenia (Grier & Cobbs, 1968; Ridley,
1984; Whaley, 1998b).
Another noteworthy feature of this study is that
schizoaffective disorder and schizophreniform disorder
were not included the schizophrenia category. Previous
investigations have included schizoaffective disorder and
schizophreniform disorder in the schizophrenia category
(e.g., Neighbors et al., 1999; Strakowski et al., 1995). The
diagnostic uncertainty about schizoaffective disorder vis-
a-vis schizophrenia and affective disorder is a topic of on-
going debate (Evans et al., 1999; Taylor & Amir, 1994).
Given these concerns, only diagnoses of schizophrenia
proper were included in that category. Thus the current
study provides a more conservative test of the overdiag-
nosis hypothesis compared with previous investigations.
METHOD
Sample
Two hundred and eighteen (76.5%) of the 285 Black
patients admitted to a state psychiatric hospital in upstate
New York met the eligibility criteria. Potential participants
had to meet the following eligibility criteria: (1) they had
to be between the ages 18 and 59; (2) they were persons
of African descent who were U.S. citizens or they immi-
grated before the age of 14; (3) they were not experiencing
a severe psychotic episode at the time of the interview; and
(4) they did not require the permission of a legal guardian
to participate. The remaining 12.6% (N = 36) were in-
eligible and 10.9% (N = 31) were discharged before be-
ing interviewed. Of the 218 eligible patients, 141 agreed
(64.7%), 56 refused (25.7%), 14 were positive conver-
sions (6.4%), and 7 were negative conversions (3.2%).
Conversions were people who initially agreed or refused
then changed their mind and refused (negative) or agreed
(positive), respectively.
The final sample consisted of 154 eligible partic-
ipants representing a participation rate of 71% for the
screening interview. There were 116 males (75%) and
38 females (25%). The average age for participants is
38.88 (S D = 9.89). The distribution by marital status is
138 (90%) single, 2 (1%) married, and 13 (9%) divorced,
separated, or widowed. The legal admission status crudely
categorized was 17 (11%) voluntary admissions and 137
(89%) involuntary admissions. Participants’ self-report of
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Cultural Mistrust and Schizophrenia
previous in-patient treatment indicated that only 11 (7%)
of them were first admissions, 33 (29%) had one to two,
and 100 (64%) had three or more past hospitalizations.
The sample breakdown by clinical diagnoses at intake was
87 (56%) schizophrenic disorders, 37 (24%) schizoaffec-
tive disorders, 10 (6%) bipolar disorders, 6 (4%) major
depressive disorders, 3 (2%) psychotic disorder NOS, 4
(3%) substance-related disorders, and 7 (5%) no diagno-
sis given.
The SCID was completed for 133 (86%) of the 154
patients who received the screening interview. The re-
maining 21 (14%) patients who did not complete the SCID
included 2 partial completions, 5 refusers, 4 discharges,
5 ineligibles, and 4 invalid (i.e., inconsistent reporting)
cases. Another 15 cases were eliminated, because some
patients denied all symptoms and the SCID interviewer
could not arrive at diagnoses for them. Unlike with clin-
ical diagnoses, it could be determined that “no diagno-
sis given” was due to reporting bias in SCID interviews.
Complete data was available for 118 (77%) cases from the
original sample.
Assessment and Diagnosis
The study was conducted in three stages. The first
stage was the screening interview conducted by two doc-
toral level African American psychologists. Black patients
were usually recruited within 2 weeks of their admission
to the hospital. After patients verbally consented to par-
ticipate, they were first given a brief mental status exam to
assess their capacity to give written informed consent. Pa-
tients who passed the mental status exam were then given
a consent form to read and sign.
Subsequently, the interviewer administered the
remainder of the screening interview, which included
the Cultural Mistrust Inventory (CMI; Terrell & Terrell,
1981); the Fenigstein Paranoia Scale (Fenigstein &
Vanable, 1992); a continuum of paranoia reflected in the
scales of Distrust (DST), Perceived Hostility of Others
(PHO), and False Beliefs and Perceptions (FBP) from
the Psychiatric Epidemiology Research Interview (PERI;
Dohrenwend, Shrout, Egri, & Mendelsohn, 1980); the
Need for Approval (NFA) Scale, which is an adapted ver-
sion of the Crowne–Marlowe Social Desirability Scale
(Crowne & Marlowe, 1960); and the Rosenberg Self-
Esteem Scale (Rosenberg, 1989). Total scores for the CMI
(1–7), Fenigstein (1–5), DST (1–4), PHO (1–4), and FBP
(1–4), NFA (0–2), and Rosenberg (1–5) were found to have
adequate reliability in this sample (Whaley, in press-b).
Upon completion of the screening, patients were debriefed
and paid $5.00 for their participation. Eligible participants
were invited to undergo the second stage interview. After
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95
each screening interview, clinical diagnoses at intake were
obtained during a review of the patient’s hospital chart by
the screening interviewer.
At the second stage, the SCID (First et al., 1996) was
administered within a week of the screening interview.
One African American female, and one White female,
master’s level psychologists, conducted the SCID inter-
views. The White female psychologist had extensive ex-
perience diagnosing severe mental illness and conducted
84% of the interviews. The African American female psy-
chologist was of Haitian descent and had less experience
diagnosing severe mental illness, so she did not qualify as
a cultural expert. Moreover, the Black and White SCID
interviewers did not differ in their ratings of cultural mis-
trust after interviewing patients (Whaley, 2001b). Partici-
pants had to sign a separate consent to receive the SCID
interview. Patients were paid $15.00 for completion of
the SCID interview. Reliability checks on the SCID diag-
noses yielded fair agreement (κ = .56 for all diagnostic
categories).
Finally, a list of significant symptoms were abstracted
from the SCID interview and submitted along with in-
formation on participant’s sex, age, residential status,
treatment status, medications, reasons for treatment, self-
reported paranoia and self-esteem, mental status data from
the chart, and a measure of their attitude toward White
clinicians in a protocol to the African American psychia-
trist or clinical psychologist for a best estimate diagnosis.
Psychometric evaluation of the best estimate diagnoses in-
dicated that the two cultural experts in their diagnoses of
paranoid schizophrenia had adequate interrater reliability,
and internal validity in their ratings of cultural mistrust
(Whaley, 2001a). All interviewers or diagnosticians were
blind to the information obtained at other stages of the
project. SCID and best estimate diagnosticians were also
blind to study hypotheses.
Statistical Analyses
The kappa statistic was the measure of agreement
among the different sources (i.e., clinical, SCID, and
best estimate) of diagnoses in terms of estimates of the
number of cases of schizophrenia. Also, agreement cate-
gories were derived from pairwise comparisons of clini-
cal, SCID, and best estimate diagnoses of schizophrenia.
For example, clinical diagnoses of schizophrenia (0,1)
were subtracted from SCID diagnoses of schizophrenia
(0,1) to yield three categories: SCID nonschizophrenia-
clinical schizophrenia (−1), SCID schizophrenia-clinical
schizophrenia or SCID nonschizophrenia-clinical non-
schizophrenia (0), and SCID schizophrenia-clinical
nonschizophrenia (1).
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96 Whaley

The agreement categories were relabeled for ease of
interpretation. To identify the source that yielded a diagno-
sis of schizophrenia in the case of disagreement in the clin-
ical/SCID comparison, for instance, the category of SCID
schizophrenia-clinical nonschizophrenia was relabeled
SCID (1), SCID schizophrenia-clinical schizophrenia
or SCID nonschizophrenia-clinical nonschizophrenia be-
came agreement (0), and SCID nonschizophrenia-clinical
schizophrenia became clinical (−1). Trichotomous out-
come variables were also created for clinical/best esti-
mate and SCID/best estimate comparisons. These agree-
ment/disagreement trichotomies were the outcomes in
multinomial logistic regression analyses with level of cul-
tural mistrust as the predictor of interest controlling for
the other predictors including the self-report of symp-
toms, lifetime comorbid substance abuse (present = 0,
absent = 1), and global assessment of functiong (GAF)
scores (0–100). These last two variables were taken from
the SCID interview.
RESULTS
Participants and nonparticipants were compared on
a number of demographic variables to assess partici-
pation bias. A significantly larger percentage of male
patients (76%) agreed initially than female patients
(56%), χ2 (1) = 7.56, p < .01. However, those who
agreed did not differ significantly from refusers in terms
of age, marital status, veteran status, type of admission
(new vs. readmit), police involvement, or involuntary
admissions.
Agreement of clinical diagnoses of schizophre-
nia with SCID and best estimate diagnoses was
poor, κ = .11, p = ns and κ = .13, p = ns, respectively.
Agreement between SCID and best estimate diagnoses of
schizophrenia was good, κ = .73, p < .0001. Estimates
of the prevalence of schizophrenia in the sample of 118
participants were 61 cases (52%) by clinical diagnosis,
46 cases (39%) by SCID diagnosis, and 45 cases (38%)
by best estimate diagnosis. According to the SCID,
there were 78 cases (66%) of lifetime and 5 cases (6%)
of current comorbid substance abuse among the 118
participants interviewed. Table I presents means and
standard deviations for all predictors to show no differ-
ence in level of symptomatology by source of diagnosis.
Multinomial logistic regression analyses of agreement on
diagnoses of schizophrenia yielded a poorly fitting model
for clinical/SCID, χ2 (18) = 24.55, p = ns, clinical/
best estimate, χ2 (18) = 19.19, p = ns, and SCID/best
estimate, χ2 (18) = 16.22, p = ns, comparisons.
Agreement among the three sources in terms of di-
agnoses of paranoid schizophrenia in the sample of 118
participants was poor for the clinical/SCID, κ = .06,
p = ns, clinical/best estimate, κ = −.00, p = ns, and
SCID/best estimate, κ = .17, p = ns, comparisons. The
number of diagnoses of paranoid schizophrenia was 30
(25%) by clinical diagnosis, 19 (17%) by SCID diagnosis,
and 20 (16%) by best estimate diagnosis. After prelimi-
nary analyses indicated that the full model overcontrolled
for paranoid symptoms, only significant or marginally sig-
nificant predictors were included in the reduced model.
The Rosenberg, Fenigstein, and PHO scales were ex-
cluded, which improved the model fit. Multinomial
logistic regression analyses of agreement on diagnoses
of paranoid schizophrenia yielded a good fitting model
for clinical/SCID comparison, χ2 (12) = 33.23, p < .001,
the clinical/best estimate comparison, χ2 (12) = 20.88,
p < .05, and SCID/best estimate comparison, χ2 (12) =
33.65, p < .001.

Table I. Means and Standard Deviations for All Predictors Used in Multinomial Logistic Regression of Agreement/
Disagreement Between Clinical and Research Diagnoses of Schizophrenia

Clinical SCID Best estimate Total sample

Measure Mean SD Mean SD Mean SD Mean SD

Cultural mistrust inventory 3.98 .85 3.55 .80 4.27 .67 4.00 .73
Global assessment of functioning 42.60 9.57 30.89 5.95 43.22 8.79 40.15 9.45
Comorbid substance abuse .57 .51 .78 .44 .70 .48 .67 .47
Distrust 2.24 .99 1.38 1.03 1.93 .93 1.92 .88
Perceived hostility of others 2.06 .99 2.42 1.18 1.60 .98 1.87 1.02
False beliefs and perceptions 1.76 1.10 2.25 .73 1.62 .77 1.64 .91
Rosenberg self-esteem 3.72 .56 3.57 .64 3.52 .48 3.55 .61
Fenigstein paranoia 2.92 .72 2.89 .89 2.73 .66 2.86 .73
Need for approval 1.31 .24 1.31 .37 1.28 .22 1.20 .28

Note. SCID = Structured Clinical Interview for DSM IV.

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Cultural Mistrust and Schizophrenia

Table II. Regression Coefficients (Standard Errors) and Odds Ratios from Multinomial Logistic Regression Analyses of Agreement/Disagreement Between Clinical and Research
Journal of Psychopathology and Behavioral Assessment (JOBA)

Diagnoses of Paranoid Schizophrenia

Clinical/SCID comparison Clinical/best estimate comparison SCID/best estimate comparison

Clinical SCID Clinical Best estimate SCID Best estimate

PP164-339991

Measure B (SE) OR B (SE) OR B (SE) OR B (SE) OR B (SE) OR B (SE) OR

Cultural mistrust inventory −.02 (.36) .98 −.47 (.48) .62 −.33 (.36) .72 .41 (.44) 1.51 −.81 (.52) .44 1.07* (.51) 2.92
Comorbid substance abuse (absent) 1.15∗ (.59) 3.16 −.77 (.76) .46 1.14 (.59) 3.13 −.69 (.67) .50 .08 (.84) 1.08 −.09 (.72) .91
Global assessment of functioning .01 (.03) 1.01 −.10∗ (.05) .90 .03 (.03) 1.03 .03 (.04) 1.03 −.11∗ (.05) .90 .01 (.04) 1.01
Distrust .73∗∗ (.32) 2.08 −.09 (.43) .91 .61∗ (.31) 1.84 .29 (.36) 1.34 −.40 (.47) .67 .35 (.37) 1.42
False beliefs and perceptions .53 (.33) 1.70 .86∗ (.44) 2.63 .73∗ (.33) 2.08 .25 (.38) 1.28 1.06∗ (.49) 2.89 −.14 (.41) .87
May 23, 2001

Need for approval 2.34∗ (1.03) 10.38 1.64 (1.37) 5.16 2.95∗∗ (1.04) 19.11 1.20 (1.15) 3.32 1.90 (1.45) 6.69 .15 (1.17) 1.16
Intercept −7.31 (2.47) −.13 (3.55) −7.62 (2.54) −7.23 (2.78) 1.53 (3.85) −7.82 (2.83)
Model χ2 33.23∗∗ 20.88∗ 33.65∗∗
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Notes. The reference category for all trichotomous outcomes was “agreement” between the two sources of diagnoses; SCID = Structured Clinical Interview for DSM IV; OR = odds ratio.
∗ p < .05. ∗∗ p < .02.
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The regression coefficients and odds ratios for the
more efficient model are presented in Table II. For the
clinical/SCID comparison, lifetime comorbid substance
abuse, the scale of DST, and the NFA scale were sig-
nificant predictors of a clinical diagnosis of paranoid
schizophrenia. The odds of a clinical diagnosis of para-
noid schizophrenia was significantly greater among pa-
tients who did not have a comorbid substance abuse,
scored high on the measure of distrust, and expressed
more social desirability. These predictors were also sig-
nificant for clinical diagnoses of paranoid schizophrenia
in the clinical/best estimate comparison with the excep-
tion of comorbid substance abuse. The GAF score and
scale of FBP were significant predictors of a SCID diag-
nosis of paranoid schizophrenia in both the clinical/SCID
and SCID/best estimate comparisons. The odds of a diag-
nosis of paranoid schizophrenia by the SCID was greater
in patients with lower GAF scores and high scores on the
measure of severe paranoia. The only significant predictor
of a best estimate diagnosis of paranoid schizophrenia was
cultural mistrust scores in the SCID/best estimate compar-
ison. A best estimate diagnosis of paranoid schizophrenia
was more likely among patients with high levels of cultural
mistrust.
DISCUSSION
Agreement among the different sources of diagnoses
was poor in five out of six comparisons. The lack of
agreement can be attributed, in part, to the fact there were
significantly more cases of schizophrenia using clinical
diagnoses than those using SCID or best estimate methods.
This finding is consistent with the the overdiagnosis of
schizophrenia hypotheses and replicates previous studies
(e.g., Neighbors et al., 1999). Similarly, the prevalence
of diagnoses of paranoid schizophrenia was greater when
clinical diagnoses were used compared with the SCID
and best estimate diagnoses. Paranoid schizophrenia is
the most frequent diagnosis given to African American
patients (Collins et al., 1980; Mukherjee et al., 1983;
Toch et al., 1987). These findings are consistent with
theoretical explanations that implicate cultural biases in
the overdiagnosis of schizophrenia in African Americans
(Adebimpe, 1981; Ridley, 1984; Whaley, 1997, 1998b).
These results suggest further that this bias occurs at the
subtype level.
Contrary to the hypothesis, however, level of cul-
tural mistrust did not predict the excess in clinical di-
agnoses of paranoid schizophrenia. Instead, it was dis-
trust and social desirability that predicted the odds of
a diagnosis of paranoid schizophrenia by clinical diag-
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Whaley
nosis. The significant correlation between patients’ self-
reported cultural mistrust and interpersonal distrust found
by Whaley (in press-b) suggests that they overlap in symp-
tom presentation. It is important to note, as I have ar-
gued in earlier works (Whaley, 1997, 1998b), that mis-
trust at the interpersonal level is different from cultural
mistrust. Clinicians who conducted the intake or admis-
sion diagnoses may have overlooked cultural expressions
of lack of trust focusing instead on the interpersonal as-
pects. Clinicians’ interpersonal orientation toward symp-
tom expression would also explain the unique contribu-
tion of social desirability to the excess of diagnoses of
paranoid schizophrenia. Socially desirable response styles
are interpersonal behaviors. Thus the diagnosticians with
a narrow interpersonal focus may be influenced by such
responses.
The possibility that culturally based responses may
be reframed as interpersonal during interracial clinical en-
counters was acknowledged by Cohen (1974). Based on
his psychotherapeutic treatment of an African American
women, Cohen (1974) cautioned White clinicians not to
interpret the initial reactions of Black clients to therapists
in terms of standard notions of transference. Transference
is a psychodynamic term to describe clients or patients’
act of projecting feelings and attitudes about a particular
significant other (e.g., a parent) onto the therapist. Cohen
(1974) stated further that Black clients’ initial reaction
to White therapists reflects more their attitude toward the
larger White society. This observation is consistent with
Maultsby (1982) and Ridley’s (1984) assertion that the
interracial therapeutic encounter elicits cultural mistrust
in the Black client because it is viewed as a microcosm
of the larger society. Moreover, my meta-analytic review
(Whaley, in press-a) of the literature on cultural mistrust
supported this point with the finding that the effect size
for the CMI is the same in studies of the mental health
context as it is in other social contexts.
Cultural mistrust was positively associated with the
odds of a diagnosis of paranoid schizophrenia by the best
estimate method. A plausible hypothesis for this finding
is that culturally sensitive African American clinicians
are better able to recognize “confluent paranoia” (Ridley,
1984; Toch et al., 1987). Ridley (1984) proposed a ty-
pology based on a 2×2 classification table with patho-
logical paranoia and cultural paranoia as two orthogonal
dimensions. If an individual is high on both dimensions,
that is, possesses both pathological and cultural forms of
paranoia, the individual has confluent paranoia (Ridley,
1984). This classification scheme implies that cultural
mistrust is the same construct in clinical and nonclini-
cal populations, but it may overlap with clinical paranoia
in chronic patient populations. Ridley (1984) recommends
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Cultural Mistrust and Schizophrenia
treatment by an African American clinician to help the pa-
tient separate out cultural forms from pathological forms
of paranoia in confluent cases. Patients presenting with
confluent paranoia may be evaluated in a manner that em-
phasizes the cultural elements and ignores the pathology
by clinicians who lack cultural competency. If this occurs,
the outcome may be the underdiagnosis of schizophre-
nia. Consistent with this argument, Whaley (2001b) rean-
alyzed the current data to test Ridley’s model of confluent
paranoia and found that SCID interviewers had difficulty
detecting confluent paranoia.
Comorbid substance abuse decreased the likelihood
that a patient would receive a clinical diagnosis of paranoid
schizophrenia. In a recent study, Trierweiler et al. (2000)
found that clinicians who made attributions of substance
abuse were less likely to give a diagnosis of schizophrenia
to African American patients. These findings suggest that
clinicians appear to interpret psychotic symptoms differ-
ently when substance abuse is present. The fact that co-
morbid substance abuse did not have significant effects on
the odds of SCID and best estimate diagnoses of paranoid
schizophrenia favors a bias explanation. Clinicians beliefs
about the cooccurrence of schizophrenia and substance
abuse should be studied. There is little empirical evidence
that substance abuse plays a causal role in schizophrenia
(Blanchard, Brown, Horan, & Sherwood, 2000). It would
be important to know whether mental health clinicians’ be-
liefs about schizophrenia and comorbid substance abuse
reflect what is known from empirical research.
The best estimate diagnosis was included in this re-
search design as the culturally sensitive component to the
psychiatric diagnosis of Black patients. This procedure
yielded the same percentage of diagnoses of paranoid
schizophrenia as the SCID, but there was little agreement
between the two types of research diagnoses suggesting
that the cases were not the same. Bias can lead to either
underdiagnosis or overdiagnosis; the former is likely to
occur when pathology is normalized by attributions of
culture (Lopez, 1989). The best estimate diagnoses may
have been culturally sensitive, but not in the way it was
planned. A methodological caveat to this interpretation is
the fact that best estimate diagnoses were based on pro-
tocols, whereas the other sources of diagnosis were based
on face-to-face interviews. Replications of this study are
needed where best estimates also include face-to-face pa-
tient interviews.
The findings of this study support the assertion that
clinicians need to be sensitive to cultural factors in the di-
agnosis and treatment of African Americans. White clin-
icians should be aware that Black patients’ perceptions
of them may reflect these patients view of the larger
White society (Cohen, 1974; Maultsby, 1982; Ridley,
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99
1984; Whaley, in press-b). Thus an assessment of Black
patients’ interracial attitudes should be included in clinical
evaluations. Also, clinicians need to be able to distinguish
between cultural and pathological aspects of paranoia
in African Americans with mental illness, especially in
those patients who present with confluent paranoia. Ridley
(1984) recommends a Black clinician for patients with
confluent paranoia. Presumably, Black clinicians have the
requisite combination of cultural knowledge and clinical
skills to be able to tease out culture and pathology in para-
noid symptom expression.
The underrepresentation of African Americans in
the mental health field reduces the chances that such
cultural experts will be available, even for consulta-
tions, so non-African American clinicians should famil-
iarize themselves with Westermeyer’s criteria for distin-
guishing culture from pathology in psychotic symptoms
(Westermeyer, 1987). Clinicians working with African
American patients should also acquaint themselves with
theory and research on cultural mistrust and other cultural
constructs relevant to Black mental health. Although these
suggestions are based on research with African Ameri-
cans, they are applicable to clinicians working with any
culturally different group.
ACKNOWLEDGMENTS
This research was supported by NIMH grant #1 R01
MH55561-01A1 to the author. The author thanks Drs.
Pamela Geller and Dawn Smyer for their substantial con-
tributions to the project. Special thanks to Ramon Recio,
Milagros Recio, Xiomara Santos, Adan Morales, and
Martin Terdomo for their volunteer work on the project.
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