How could Mr A’s and Mr. B’s doctors have avoided their initial misdiagnoses?
Dr. Benzick’s observations
“Cultural paranoia” describes adaptive or healthy responses by African-Americans living in a society they perceive as racially prejudiced.8 Several researchers have studied this concept of protecting self-esteem by blaming an external source for negative events. Women who plausibly attribute unflattering feedback to prejudice exhibit higher self-esteem.9 A person who believes he or she is a target of discrimination identifies more strongly with his or her racial or ethnic group, leading to reduced depression, higher self-esteem, and improved psychological adjustment.9
Perceived discrimination, however, can also elicit feelings of hopelessness and resignation when it leads to widespread bias against the alleged oppressing racial or ethnic group. The resulting sense of social exclusion has been linked to lower self-esteem and higher rates of anxiety and depression.9 Thus, the individual’s environment and ability to develop relationships will determine whether “cultural paranoia” is “adaptive.”
Paranoia or prejudice? Distinguishing culturally sanctioned “paranoia” from “prejudice” can be difficult. “Prejudice” is defined as the negative evaluation of a group or individual based on group membership.10 “Paranoia” (using the DSM-IV definition of “paranoid ideation”) is a belief of less than delusional intensity “involving suspiciousness or the belief that one is being harassed, persecuted, or unfairly treated.”2
So while an individual may be prejudiced toward a group, cultural paranoia would exist only if other family members or acquaintances believe the other group is conspiring against them. Additionally, while prejudice tends to be ego-syntonic,11 paranoia is more distressing because it produces heightened vigilance and possibly fear.
Both cases describe how a lack of cultural understanding between African-American patients and physicians of other ethnicities or races can lead to misdiagnosis of psychosis.12 They also illustrate that while prejudice may be tightly focused (eg, hatred of anyone from a specific racial or ethnic group), paranoid ideation can be generalized. For example, Mr. A believed that his wife, an African-American, conspired with his white supervisors against him.
Mr. A’s and Mr. B’s depressive and anxiety symptoms unmasked longstanding, deeply rooted beliefs. Both patients’ neurovegetative symptoms responded to medication and brief psychotherapy, and both returned to prior levels of functioning. The underlying mistrust remained, however.
Related resources
- Lu FG. Annotated bibliography on cultural psychiatry and related topics-June 2003. Available at: http://www.admsep.org/culture.html. Accessed July 18, 2003.
- Forsell Y, Henderson S. Epidemiology of paranoid disorders in an elderly population. Br J Psychiatry 1998; 172:429-32.
Drug brand names
- Fluoxetine • Prozac
- Olanzapine • Zyprexa
- Nortriptyline • Aventyl, Pamelor
- Paroxetine • Paxil
- Venlafaxine • Effexor
Disclosure
Dr. Benzick reports no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.