Schizophrenia: An African American Epidemic

Causes, Effects, and Resolutions for Misdiagnosis of

African Americans in the Mental Health Sector

 

This is an introduction to a lengthy paper. 

If you would like to read the rest of this paper, please click on the link below.

Misdiagnosis of Schizophrenia in African Americans

 

Abstract

Many studies have shown that African Americans are frequently misdiagnosed with schizophrenia, but the reason for this disparity is still unknown. Contributing causations may be symptom misinterpretation, lack of research, and bias, to name a few. Misdiagnosis harms a plethora of African Americans each year due to improper treatment and the effects thereof. Researching what factors play a role in the misdiagnosis trend, as well as implementing cultural competency standards and education for mental health professionals should be the first steps taken to ensure African Americans have the right to equal mental health treatment. 

Introduction

          In the United States society, the ill-treatment of people of color is manifest in health conditions (National Association of Social Workers [NASW], 2001). Accordingly, the psychiatric treatment of African Americans has been carried out on an institution of stereotypical views toward their racial group (Feagin, Early, & McKinney, 2001). Over 18 million adult Americans develop a mood disorder each year, whereas only two million, or a mere one percent of the U.S. population, develops schizophrenia (Kimmon, 2005). How is it, then, that African Americans with mood disorders or depression are more often than not diagnosed with schizophrenia (Kimmon)?  Does the African American race have a greater tendency to develop schizophrenia?

          Actually, it seems to be quite the contrary. Non-biased studies have shown once factors such as socioeconomic status are taken into account, there are comparable rates of schizophrenia in Caucasians and African Americans. Even so, the pattern of schizophrenic misdiagnosis is more prevalent in African Americans (Colorado Department of Public Health and Environment [CDPHE], 2005). “Research has already shown that African American patients are being improperly diagnosed, but we need to find out why” (Kimmon, 2005).

Family and Friends of Individuals with Bipolar Disorder

Family and friends may be able to provide more accurate information about the patient’s mental condition than the patient themselves.  While they may not know what the patient is feeling, they can give an account of the patient’s behavior from day to day.  In addition, co-workers, instructors, and individuals who frequently come into contact with the individual may provide significant details pertaining to his or her condition. 

If it is confirmed that a patient has family members with a mental disorder, especially immediate family members with bipolar disorder, than the chances of inheritance are great.  Sometimes a genetic link may be the most significant clue of a full-blown or impending case of bipolar disorder.  If a patient has a parent with bipolar disorder and presents with symptoms of depression, then special attention should be given. Bipolar I disorder often begins with depression, so even if mania has not yet arisen, the individual should be carefully monitored for signs of extremely elevated or irritable moods.

 

Bipolar disorder is a difficult disorder to both diagnosis and to live with.  Family members are often affected as much as the patient.  Children with a bipolar parent may live in constant fear of their parent’s extreme mood swings and bear the major blunt of the disorder.  Many times a child may feel it is his or her fault when a parent is depressed or that he or she did something to cause the parent to become angry.  Spouses have it no easier.  The destructive behavior manic patients often engage in may have serious consequences, not just for themselves, but to their relationship as well.  A manic individual may desire sexual intercourse constantly or engage in dangerous sexual practices.  A family may go bankrupt due to a manic induced spending spree. A manic individual may be extremely volatile and have violent outbursts over the most insignificant things. 

 

When a patient comes off of a manic high, the situation is no better.  Depression is almost inevitable, and the consequences of their manic episodes often arise, causing an even deeper form of depression.  Considering how frequent suicide is in patients with bipolar disorder, families may live in a constant state of worry.  If an individual does commit suicide, family members often blame themselves as well.  Family members of individuals with bipolar disorder often experience mental disorders, even when there is no genetic link. The stress and anxiety of trying to take care of, and live with, a bipolar individual is great.  A clinician should not only assess a patient with bipolar disorder, but the family members as well.    

Diagnosing Bipolar Disorder

Bipolar Disorder is often a difficult syndrome to diagnosis.  Patients are much more likely to seek treatment when suffering from depression than mania, and many times patients may be less than truthful when discussing their “highs”, whether intentionally or unknowingly.  While a psychiatrist may easily see symptoms of bipolar disorder when a patient is treated over a long period of time, misdiagnosis is frequent on the first visit.  Often times, an inexperienced clinician may view a person experiencing mania or hypomania as a very happy, lively, and enthusiastic individual.  Manic patients’ moods can be very infectious. 

Paying close attention to speech and body language is an important diagnostic tool. Patients with depression may speak slowly and quietly with their heads down, have a flat-tone, and show little emotion. Men may appear unshaven. Clothing may be wrinkled, and patients may have an overall downtrodden look. On the other hand, manic patients may talk quickly and loudly, frequently using jokes or puns. Their speech may be incoherent or consist of a “flight of ideas”, jumping from one topic to the next.  Often provoked to anger, the simple suggestion of mania may cause a patient to become irate.  Clinicians must be aware of the emotional unstableness of manic patients because violent outbursts are common.

As manic patients are often unaware of the mental state they are in or have previously been in, getting an accurate history of the patient may be difficult.  While lying may be intentional because a patient is experiencing a “high” and does not want to come down, individuals may not be able to give a truthful account, regardless of their sincerity. Clinicians should try to gather information such as past medical records, criminal incidents, and job history. Inability to maintain a job, especially when performance was satisfactory for a length of time, may be an indicator. Also, sexually transmitted diseases, and maxed-out credit cards may be consequences of a manic episode. Substance abuse, which is common in bipolar disorder, should be taken into consideration as well.

Case Study and Hypothetical Explanation

Bill is a middle aged, married, Caucasian male who has two grown children. Bill’s father passed away when Bill was in college, and this loss still pains him. He held his father in extremely high regard and at times referred to him as “brilliant” even though his father did not graduate from high school. His father worked at a skilled trade until he suffered a fatal illness in his late 40s or early 50s. Bill laments the loss of his father and, in particular, the guidance he thought his father could have provided during turbulent times in Bill’s life. According to the pattern of alcohol use that Bill describes, it is likely that Bill’s father had a serious drinking problem, if he was not actually an alcoholic. His mother, who is also dead, is described by Bill as a strong woman and the matriarch of the family. While he states that he had much respect for her, it seems that his respect was also tinged with fear of her disapproval. She never accepted or understood why he chose the college he did and why he had an interest in an Army career.Bill states that his mother never used alcohol. He describes her as a very critical and judgmental person. His family of origin was devout in their religious beliefs, and this appears to play a significant role in his life. He is close to his siblings, but they do not talk often, and he feels guilt for not initiating calls to them. His hesitation to call them is due in part to a fear that they will reject him. It is for this reason that he also tries to keep conversations with them at a superficial level. His extended family includes people who have achieved at the highest levels of government and their professions.Bill graduated from a prestigious college and embarked on a military career, which was his lifelong ambition. A “vindictive” superior officer who gave him poor performance evaluations cut this short. It turns out that Bill may have had much more of a role in this than he admits initially or is aware of. He acknowledges a lengthy period of indecision and marginal adherence to military standards at the beginning of his career. Nonetheless, he developed the persona of hero in both military matters and civilian jobs, and to this day, he compares himself with heroic figures from antiquity and sees himself on the verge of doing something great.Since his discharge from the Army, he has held at least five or six jobs in which he seemed to do well, until he was ultimately fired for reasons that are not entirely clear. It appears that the terminations were due to personality conflicts or nepotism by the owner of the business. He has been unemployed for the last three years. Bill is frightened about applying for another job because of the possibility of rejection or failure (being fired again).Bill places unrealistic importance on the support available from his nuclear family. Yet, he says he is cautious around them because if he says or does the wrong thing they might leave him or tell him to leave. He expresses anger at his adult children because they do not appear as devoted to him as he was and still is to his late father. However, he keeps this anger to himself for fear of rejection. He also experiences this conflict with his wife of many years. It is not possible for her to meet his expectations for support, so he becomes angry with her, but withholds the expression of his anger for fear of alienating her.

He has great difficulty getting out of bed in the morning and constantly thinks about suicide. While he feared death as a young man, now he says he would welcome it. He has been on psychotropic medication for years and questions whether it is working. Bill is awash in guilt. He feels guilt for things he has done and things he has not done. He has a disarming smile that belies the pain he feels and keeps people from prying into his life. He has one or two drinks of Jack Daniels neat each night. Psychotherapy is difficult with him because of the chronic nature of his problems and his fear of alienating people who are close to him. He seems to genuinely believe that his expectations of other people are fair and reasonable.

 Hypothetical Explanation:

Axis 1: 1.  Major Depressive Disorder, Moderate

One of the primary symptoms of Major Depressive Disorder is a depressed mood, most of the day, occurring nearly every day.  Though we do not have a detailed account of Bill’s history, it seems as if he never got over the death of his father. It appears that Bill believes if only his father were still alive that he would be able to cope and get through the “hard times”, but that he is not capable of this due to his father’s death.  His father’s death may have been the starting point of his depression.

Only three percent of patients suffering from depression do not experience reduced energy, difficulty finishing tasks, or impaired functioning at work or in school (Sadock, 2003).  Bill’s loss of his military career may have been a precursor to his depression; and his inability to keep a job, as well as his three-year stretch of unemployment, may have been a consequence of Major Depressive Disorder. Though we do not have a complete history of Bill’s depressive symptoms, considering his marital discord, it is likely that he also has a diminished sexual relationship.

Individuals with Major Depressive Disorder often suffer from feelings of excessive or inappropriate guilt; Bill does both.  He constantly feels guilty about things he has and hasn’t done. He states he is “awash” in guilt.  He fears to call his siblings, but feels guilty when he doesn’t.  This anxiety Bill experiences, which is present in 90 percent of cases (Sadock, 2003), is a common occurrence in this disorder.

Bill also complains about getting out of bed in the morning.  Patients with depression often complain of sleeping difficulties.  Either an excessive amount of sleep is needed, or insomnia is present.  This excessive need to sleep that plagues Bill is most likely related to diminished interest in every-day activities.  Bill has trouble with getting out of bed because he feels he has nothing to look forward to and that it will be another painful day.

The most dangerous, and perhaps severe, symptom of depression is suicidal ideation. Suicide is a definite warning sign for patients with severe depression.  Around two-thirds of all depressed individuals consider suicide, and tragically ten to fifteen percent actually commit the deed. Bill’s constant thoughts of suicide need to be addressed immediately.   

2.  Alcohol Abuse

Bill reports a drinking habit of one to two drinks a night.  This would put Bill in the category for “moderate drinking” (Sadock, 2003) and would not necessarily indicate he has a drinking problem.  However, considering his father, who he seemed to idealize, likely had a severe drinking problem, the chances are strong that Bill has the tendency to be a victim of alcohol abuse.  Studies have shown that having a parent who is affected by an alcohol-related disorder increases the chance that the child will also develop a similar disorder later in life (2003).  In addition, individuals with an alcohol disorder, especially when combined with Major Depressive Disorder, are at a greater risk of committing suicide (2003).  This problem should be addressed immediately, before it worsens or couples with the depression to produce hazardous effects.

Axis 2: Passive-Aggressive Personality Disorder

Though it is quite evident Bill is likely suffering from a personality disorder, it is difficult to accurately determine the correct diagnosis due to inadequate information and varying symptoms.  Bill has some features of Narcissistic Personality Disorder and Avoidant Personality Disorder.  However, with the description given, Passive-Aggressive Personality Disorder seems to be a good fit. This disorder cannot solely occur during Major Depressive Disorder, but unless Bill’s depression began before his military career ended, it does not seem to be exclusive to his depression.

Bill’s entire demeanor seems to consist of much anger and brooding, but with little expression of his emotions.  After Bill’s initial loss of his military career, he was not successful in keeping a job, and he gave up because of fear he would fail or be rejected once again.  This could fall under the symptom of “passively resists fulfilling routine social and occupational tasks” (Sadock, 2003). He speaks of his commanding officer as “vindictive” and though the cause of his other terminations is unknown, he attributes being fired to favoritism or bias by his employers (“voices exaggerated and persistent complaints of personal misfortune”, 2003).  Individuals with Passive-Aggressive Personality Disorder often scorn and irrationally criticize authority (2003).  This seems to be the case with Bill.  He blames his commanding officer for his military problems, but does admit to having little to no adherence to military rules during the beginning of his career.

Bill appears to be in utter turmoil with himself; one minute he is full of guilt and the next he is angry and blaming others for letting him down. Alterations between remorse and insubordination are common in Passive-Aggressive Personality Disorder. It is very likely this is the reason for his career failure.  Considering his performance looks to be adequate in all of his job endeavors, the “personality conflicts” Bill speaks of must have great significance.

His personal relationships are no more successful.  He is constantly at odds with his family (“complains of being misunderstood and unappreciated by others”, Sadock, 2003).  He has unreal expectations of the support they should give him. He stays angry at his wife because she doesn’t support him in the way he feels she should, and also feels scorn towards his children because they are not as devoted to him as he feels he was, and is, to his father.

Even though Bill has a great amount of anger, he does not express this anger for fear of rejection.  In addition, he rarely calls his siblings because of this fear of rejection and feels guilty when he doesn’t; yet, when he does, he only discusses superficial topics because he is afraid of getting hurt.  These latter characteristics of fear of rejection and intimate relationships could be described as features of Avoidant Personality Disorder.  Bill tries to avoid any kind of relationship or activity that he could possibly experience rejection in again. Bill speaks of fear of his mother’s disapproval and describes her as being “critical and judgmental”. Bill’s fear of rejection likely stemmed from childhood, but grew stronger when additional rejection occurred.     

Another feature that seems somewhat out of character with Bill’s other symptoms is his narcissistic, grandiose sense of self-importance.  While working in the military and other positions, Bill started to see himself as a hero and “on the verge of doing something great”. While it may seem somewhat odd that Bill is so depressed when he has such a high regard for himself, Edward Bibring describes depression as an occurrence that begins when an individual becomes conscious of the incongruity between extremely lofty standards and the incapacity to meet these objectives (Sadock, 2003).

Axis 3:  No Diagnosis.

There is no physical health issue presented, but this possibility cannot be ruled out until a full medical workup is completed.

Axis 4: Loss of Career/Unemployment and Family Dissension

Individuals who are unemployed are three times more likely to suffer from depression (Sadock, 2003).  Bill pursued a military career even after the disapproval of his mother, and the disappointment of losing this position had to have a major effect on him.  Not only did Bill lose one job, he lost half a dozen others. This type of failure is enough to cause a mentally stable individual substantial turmoil. 

In addition, it sounds as if Bill has always had problems with his family life.  Though he speaks highly of his father, the possibility that he was a severe alcohol abuser should be taken into consideration.  He expresses his mother as being “devout in her spiritual beliefs” and never using alcohol. This likely caused conflicts between his parents. Regardless, Bill conveys the fear he had of his mother. Progressing to his married life, Bill has had problems with marital discord, little contact with siblings and feelings of abandonment by his children.

Axis 5:  GAF = 35

The GAF rating between 31-40 is defined as “some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking or mood” (Sadock, 2003).  Bill has substantial impairment in his professional and social life, along with suicidal ideations.

Sadock, Benjamin & Sadock, Virginia. (2003). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (9th ed.). Philadephia: Lippincott Williams & Wilkins. 

Description of Bipolar Disorder

Bipolar disorder, which was once termed manic-depressive disorder, is a mood disorder that affects around one percent of the population.  Unlike major depressive disorder, the prevalence of bipolar disorder is the same in men and women.  However, men are more likely to suffer from manic episodes and women from depressed episodes.  When women do experience mania, they are more liable to experience mixed episodes and rapid-cycling. Five to fifteen percent of individuals with bipolar disorder experience rapid-cycling, or having four or more manic episodes in a year (Sadock, 2003).

Two irregular mental states, depression and mania, are the hallmarks of the syndrome. A mixed episode, which meets the criteria for mania and major depression, may also occur.  The symptoms of depression displayed in bipolar disorder are consistent with that of major depressive disorder, including a depressed mood, weight loss or decreased appetite, fatigue, insomnia or hypersomnia, feelings of worthlessness or guilt, psychomotor agitation or retardation, a diminished ability to think, recurrent thoughts of death, and diminished pleasure in activities (Sadock, 2003).

 

Mania is defined as an abnormally elevated, irritable, or expansive mood lasting for a period of a week or longer (if untreated, three months on average) that causes marked impaired functioning. The normal onset is rapid- a few hours or days, but the state may evolve over a few weeks (Sadock, 2003). Symptoms include distractibility, a flight of ideas, a decreased need for sleep, increased talkativeness, inflated self-esteem, an increase in goal-directed activity or psychomotor agitation, and an excessive involvement in possibly detrimental, pleasurable activities (2003).  In severe cases of mania, psychotic features may be present, including delusions or hallucinations.  Patients with mania, especially those with psychotic features, may need hospitalization to keep from harming themselves or others. 

Patients with hypomania, a less severe form of mania, experience similar symptoms to those with mania, but do not have impaired functioning.  Episodes only have to last for four days or more rather than a week, hospitalization is not necessary, and psychotic features are not present (Sadock, 2003).  Even so, symptoms are noticeable by others and individuals in a hypomanic state have an unmistakable heightened level of functioning.

 

There are two main categories of bipolar disorder, Bipolar I and Bipolar II disorder.  To be diagnosed as having Bipolar I, a patient must have experienced at least one manic mood and one episode of major depression or a mixed episode. Bipolar I normally commences with depression; and the earlier the onset, the poorer the prognosis (Sadock, 2003).  Fortunately, around seven percent of individuals with Bipolar I disorder do not have a recurrence of symptoms. However, around a third of patients have persistent symptoms and social decline (2003). The criteria for Bipolar II disorder consists of at least one major depressive episode and hypomanic episode, without any periods of mania or mixed episodes.  Unlike Bipolar I disorder which may have permanent remittance however infrequent, Bipolar II disorder is a chronic, long-term disease. 

To read the symptoms of bipolar disorder is one thing; to experience them is a totally different situation.  Imagine being on a roller coaster. When the coaster is sitting still, the patient is stable, but may very well have an impending sense of dread for what is about to happen. Then the roller coaster starts climbing the hill.  One could equate this to the evolution of a manic episode.  Sleep starts to diminish and the mood starts to elevate.  The “rider” no longer has a sense of dread because he or she gets excited, elevated, and feels as if he or she can do anything. Then the ride truly begins.  Thoughts start flowing rapidly and the individual wants everyone to feel what he or she is feeling and has a desperate “need” to talk to anyone who will listen.  Things are truly wonderful and the world is a nice place to live.  However, once the ride goes on for a while, things begin to get confusing.  Everything seems to be rapidly flying past, but things start to make less and less sense.  Words don’t come out as fluently and this sense of elevation starts to become a source of extreme irritation. Everything starts to become exasperating.  Then the ride slowly comes to a stop.  The sense of elevation suddenly ends and the excitement is over.  After such a ride and being able to accomplish so much, what is left?  Every day life seems boring and thoughts are still muddled. The individual no longer wants to be around anyone because he or she has nothing to say.  Words don’t come out right anymore, and no one can understand what they are feeling. The only thing left is death because he or she no longer has anything left to give.  Of course, this is only a simplistic analogy of some of the symptoms patients experience when bipolar, but hopefully it provides a little insight into the disorder.

Anxiety Symptoms in Hypothyroidism

Hypothyroidism, one of the most common endocrinological conditions associated with anxiety (Hall, 2002), is a state in which the body does not produce enough of the thyroid hormone (EndocrineWeb.com, 2005). One of the most common causes of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis, which is an inflammation of the thyroid gland caused by an individual’s own immune system.  This inflammation will damage or destroy cells, leaving them incapable of producing an adequate amount of hormones (2005).  However, there are other causes, for i.e. individuals that do not produce enough hormones due to a problem with the pituitary gland (2005).

The main diagnostic tool for hypothyroidism is a blood test; if the thyroid hormone (TH) level is below normal range, then a patient most likely has hypothyroidism (EndocrineWeb.com, 2005).  Normally, an individual will have a high thyroid stimulating hormone (TSH) level along with a low TH level because the pituitary gland is trying to overcompensate for the lack of TH created (2005).

There is a wide range of severities within hypothyroidism, and the severity of symptoms does not always correlate with the severity of the disorder (EndocrineWeb.com, 2005). Some common physical symptoms are fatigue and lethargy, diminished libido, headaches, weakness, cold intolerance, and dry skin; physical signs include thin, course hair, pallor, brittle nails, and a slowed pulse (Hall, 2002).  Once the disease progresses, vision and hearing deficiencies, weight gain, inability to sweat, muscle cramps, and several other symptoms often arise.

Psychiatric symptoms, such as anxiety, are often the first indicators of hypothyroidism (Hall & Lowrance, 2002, & 2006).  Anxiety disorders occur in approximately 30-40% of patients with emerging acute hypothyroidism (Hall, 2002).  Severe anxiety attacks, panic attacks, and “free floating anxiety”, or a continuous feeling of being on edge, are all common anxiety reactions when hypothyroidism is developing (Lowrance, 2006). 

Hall (2002) reports the rapidly changing hormone levels in hypothyroidism is a key factor in the development of anxiety symptoms.  Patients with myxedema, a condition caused by hypothyroidism which involves blunting of the intellect and senses, thickening skin, and labored speech, present with progressive anxiety accompanied with generalized anxiety (2002).  Delusions, hallucinations, paranoia, and extreme restlessness mixed with lethargy are all common in individuals with myxedema.  Patients with more gradual drops in hormone levels still present with anxiety symptoms, but normally have a type of “chronic anxiety”. 

Lowrance (2006) reports in Hashimoto’s Disease that anxiety symptoms can be attributed not only to the abnormal thyroid levels, but also to the autoimmune disease process.  Anti-thyroid-peroxidase and anti-thyoglobulin, two anti-thyroid antibodies, can cause depression and anxiety symptoms even before hormone levels are out of the normal range (2006).  Lowrance states, “Researchers describe the anxiety symptoms from autoimmune hypothyroidism, as being caused by the gland’s attempts to ‘sputter back to life’ as it begins to fail and in attempt to fight off the autoimmune attack.  The actual medical term for this is ‘Hashitoxicosis’ and patients will have it to varying degrees but usually…causes significant anxiety symptoms.” 

When psychiatric clinicians are initially analyzing a patient, medical conditions must be considered before a diagnosis is made.  Some subtle differences may alert a clinician of the differences between psychologically caused and medically caused anxiety disorders.  For instance, medically induced anxiety disorders often show instability in the duration and severity of panic attacks or anxiety (Hall, 2002).  In addition, patients with anxiety disorders that form prior to the age of eighteen or after the age of 25 and who have a negative personal and family history of anxiety should be closely analyzed for an underlying medical condition (2002).  Hall reports that anywhere from 10-40% of medical patients with anxiety disorders are thought to have an organic etiology for their symptoms. 

The importance of taking medical conditions into consideration when diagnosing psychiatric patients is great.  If the anxiety disorder is truly organically induced, a patient will not recover psychologically without treatment of the physical disorder. Because emotional symptoms often arise before any physical symptoms in hypothyroidism, both patients and clinicians often make the mistake of attributing the disorder to a mental health problem.  While psychiatric drugs alone cannot cure the psychological symptoms involved during hypothyroidism and may in fact make the situation worse, drugs that treat the hypothyroidism will normally cure the anxiety symptoms, as well as the medical condition.  Lowrance (2006) exclaims, “Remember, thyroid diseases are a major cause and possibly the most common ‘medical cause’ of emotional symptoms!”

The articles presented by EndocrineWeb.com (2005), Hall (2002), and Lowrance (2006) provide both solid explanations and examples for anxiety symptoms presented in hypothyroidism.  Though the exact medical etiology is debatable and may involve a combination of factors, the high correlation of anxiety symptoms in patients with hypothyroidism supports the organic basis of psychological symptoms. Some symptoms of anxiety may be brought upon by the stress of having the disorder; but considering anxiety symptoms often precede any physical symptoms, this seems unlikely to be the sole cause.   

References:

EndocrineWeb.com. (2005). Hypothyroidism. Retrieved October 17, 2006 from http://www.endocrineweb.com/hypo1.html

Hall, Richard. (2002). Anxiety and Endocrine Disease. Retrieved October 17, 2006 from http://www.drrichardhall.com/anxiety.htm

Lowrance, Jan & Jim. (2006). Anxiety and Depression Symptoms in Thyroid Disease.  BellaOnline.  Retrieved October 17, 2006 from http://www.bellaonline.com/articles/art41515.asp